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Health and Access to Care among Reproductive-Age Women by Sexual Orientation and Pregnancy Status

Published:November 19, 2018DOI:https://doi.org/10.1016/j.whi.2018.10.006

      Abstract

      Background

      A large body of research has documented disparities in health and access to care among sexual minority populations, but very little population-based research has focused on the health care needs among pregnant sexual minority women.

      Methods

      Data for this study came from 3,901 reproductive-age (18–44 years) women who identified as lesbian or bisexual and 63,827 reproductive-age women who identified as heterosexual in the 2014–2016 Behavioral Risk Factor Surveillance System. Logistic regression models were used to compare health care access, health outcomes, and health behaviors by sexual orientation and pregnancy status while controlling for demographic characteristics and socioeconomic status.

      Results

      Approximately 3% of reproductive-age sexual minority women were pregnant. Pregnant sexual minority women were more likely to have unmet medical care needs owing to cost, frequent mental distress, depression, poor/fair health, activity limitations, chronic conditions, and risky health behaviors compared with pregnant heterosexual women. Nonpregnant sexual minority women were more likely to report barriers to care, activity limitations, chronic conditions, smoking, and binge drinking compared with nonpregnant heterosexual women. Health outcomes were similar between pregnant and nonpregnant sexual minority women, but pregnant sexual minority women were more likely to smoke cigarettes every day compared with other women.

      Conclusions

      This study adds new population-based research to the limited body of evidence on health and access to care for pregnant sexual minority women who may face stressors, discrimination, and stigma before and during pregnancy. More research and programs should focus on perinatal care that is inclusive of diverse families and sexual orientations.
      A large body of research has documented disparities in health and access to medical care for sexual minority populations (
      • Blosnich J.R.
      • Farmer G.W.
      • Lee J.G.L.
      • Silenzio V.M.B.
      • Bowen D.J.
      Health inequalities among sexual minority adults.
      ,
      • Conron K.J.
      • Mimiaga M.J.
      • Landers S.J.
      A population-based study of sexual orientation identity and gender differences in adult health.
      ,
      • Gonzales G.
      • Przedworski J.
      • Henning-Smith C.
      Comparison of health and health risk factors between lesbian, gay, and bisexual adults and heterosexual adults in the United States: Results from the National Health Interview Survey.
      ,
      Institute of Medicine
      The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding.
      ). Lesbian, gay, bisexual (LGB), and other nonheterosexual people are more likely to report adverse health outcomes owing to minority stress, or the additional stressors associated with being a member of a marginalized minority group (
      • Eliason M.J.
      Chronic physical health problems in sexual minority women: Review of the literature.
      ,
      • Meyer I.H.
      Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence.
      ). Discriminatory environments and stigma against LGB populations can lead to lower self-esteem, less confidence, and increased rates of mental distress and risky health behaviors, including heavy cigarette smoking and alcohol consumption (
      • Hatzenbuehler M.L.
      • Keyes K.M.
      • Hasin D.S.
      State-level policies and psychiatric morbidity in lesbian, gay, and bisexual populations.
      ). Meanwhile, limited access to health insurance and to culturally competent health care providers trained on LGB health issues may create barriers to regular medical care (
      • Clift J.B.
      • Kirby J.
      Health care access and perceptions of provider care among individuals in same-sex couples: Findings from the Medical Expenditure Panel Survey (MEPS).
      ,
      • Gonzales G.
      • Blewett L.A.
      National and state-specific health insurance disparities for adults in same-sex relationships.
      ). Indeed, LGB populations are less likely to receive routine medical care, and they continue to experience challenges finding LGB-affirming providers (
      • Dahlhamer J.M.
      • Galinsky A.M.
      • Joestl S.S.
      • Ward B.W.
      Barriers to health care among adults identifying as sexual minorities: A US national study.
      ,
      • Hsieh N.
      • Ruther M.
      Despite increased insurance coverage, nonwhite sexual minorities still experience disparities in access to care.
      ).
      Very little research has focused on health and access to care for sexual minority women during pregnancy. Rather, research on pregnancy among sexual minority populations has tended to focus on sexual behaviors and risk of pregnancy. For instance, several studies have compared the lifetime prevalence of pregnancy in sexual minority women relative to heterosexual women; these studies found that sexual minority women were less likely to ever be pregnant compared with heterosexual women (
      • Hodson K.
      • Meads C.
      • Bewley S.
      Lesbian and bisexual women’s likelihood of becoming pregnant: A systematic review and meta-analysis.
      ,
      • Marrazzo J.M.
      • Stine K.
      Reproductive health history of lesbians: Implications for care.
      ). Some research, however, suggests that sexual minority adolescents may be more likely to engage in sexual behaviors and report greater risks of pregnancy compared with heterosexual adolescents (
      • Charlton B.M.
      • Roberts A.L.
      • Rosario M.
      • Katz-Wise S.L.
      • Calzo J.P.
      • Spiegelman D.
      • Austin S.B.
      Teen pregnancy risk factors among female adolescents of diverse sexual orientations.
      ,
      • Everett B.G.
      • McCabe K.F.
      • Hughes T.L.
      Unintended pregnancy, depression, and hazardous drinking in a community-based sample of sexual minority women.
      ,
      • Lindley L.L.
      • Walsemann K.M.
      Sexual orientation and risk of pregnancy among New York City high-school students.
      ,
      • Saewyc E.M.
      • Bearinger L.H.
      • Blum R.W.
      • Resnick M.D.
      Sexual intercourse, abuse and pregnancy among adolescent women: Does sexual orientation make a difference?.
      ,
      • Saewyc E.M.
      • Poon C.S.
      • Homma Y.
      • Skay C.L.
      Stigma management? The links between enacted stigma and teen pregnancy trends among gay, lesbian, and bisexual students in British Columbia.
      ). This research was important for correcting misconceptions that sexual minority women cannot or do not wish to become pregnant—beliefs that have stalled progress on research that aims to address the health care needs of pregnant sexual minority women (
      • Estes M.L.
      “If there’s one benefit, you’re not going to get pregnant”: The sexual miseducation of gay, lesbian, and bisexual individuals.
      ). Our study builds on previous research and begins to fill wide gaps in knowledge on pregnant sexual minority women using data from a large, representative, and multistate health survey to compare access to care, health status, and health behaviors by sexual minority and pregnancy status.

      Conceptual Framework

      There are a variety of reasons why pregnant sexual minority women may be at greater risk of experiencing adverse health outcomes during pregnancy compared with heterosexual women. First, numerous studies (predominantly focusing on heterosexual women or assuming heterosexual identities) have found that some women are more likely to report anxiety and stress during pregnancy (
      • Schetter C.D.
      Psychological science on pregnancy: Stress processes, biopsychosocial models, and emerging research issues.
      ,
      • Schetter C.D.
      • Tanner T.
      Anxiety, depression and stress in pregnancy: Implications for mothers, children, research, and practice.
      ,
      • Woods S.M.
      • Melville J.L.
      • Guo Y.
      • Fan M.Y.
      • Gavin A.
      Psychosocial stress during pregnancy.
      ). Elevated stress levels during pregnancy are associated with miscarriages, preterm births, and low birthweight infants (
      • Newton R.W.
      • Hunt L.P.
      Psychosocial stress in pregnancy and its relation to low birth weight.
      ,
      • Schetter C.D.
      Psychological science on pregnancy: Stress processes, biopsychosocial models, and emerging research issues.
      ,
      • Schetter C.D.
      • Tanner T.
      Anxiety, depression and stress in pregnancy: Implications for mothers, children, research, and practice.
      ) as well as risk factors (e.g., cigarette smoking) associated with these birth outcomes (
      • Lobel M.
      • Cannella D.L.
      • Graham J.E.
      • DeVincent C.
      • Schneider J.
      • Meyer B.A.
      Pregnancy-specific stress, prenatal health behaviors, and birth outcomes.
      ,
      • Weaver K.
      • Campbell R.
      • Mermelstein R.
      • Wakschlag L.
      Pregnancy smoking in context: The influence of multiple levels of stress.
      ). Although pregnancy itself can be stressful for women, sexual minority women may also encounter structural and interpersonal discrimination directed against them—which may compound stress levels during pregnancy. Several qualitative studies have documented the care experiences of sexual minority women across the perinatal period; most of this research has focused on sexual minority women using assisted reproductive technology (ART). These studies find that female same-sex couples may experience challenges navigating the health care system—particularly when ART is not covered by medical insurance or when couples lack familial and social supports (
      • Rank N.
      Barriers for access to assisted reproductive technologies by lesbian women: The search for parity within the healthcare system.
      ,
      • Ross L.E.
      • Steele L.S.
      • Epstein R.
      Service use and gaps in services for lesbian and bisexual women during donor insemination, pregnancy, and the postpartum period.
      ,
      • Yager C.
      • Brennan D.
      • Steele L.S.
      • Epstein R.
      • Ross L.E.
      Challenges and mental health experiences of lesbian and bisexual women who are trying to conceive.
      ). Meanwhile, identifying a sperm donor can raise practical, legal, and ethical challenges for some same-sex couples, such as deciding to choose a known or unknown sperm donor (
      • Hayman B.
      • Wilkes L.
      • Halcomb E.
      • Jackson D.
      Lesbian women choosing motherhood: The journey to conception.
      ). The issues and unique stressors surrounding the ART process may also cause some sexual minority women to experience depression and anxiety (
      • Borneskog C.
      • Sydsjö G.
      • Lampic C.
      • Bladh M.
      • Svanberg A.S.
      Symptoms of anxiety and depression in lesbian couples treated with donated sperm: A descriptive study.
      ), especially when couples experience unsuccessful attempts or miscarriages (
      • Chapman R.
      • Wardrop J.
      • Zappia T.
      • Watkins R.
      • Shields L.
      The experiences of Australian lesbian couples becoming parents: Deciding, searching and birthing.
      ,
      • Peel E.
      Pregnancy loss in lesbian and bisexual women: An online survey of experiences.
      ). Some, but not all, sexual minority women undergoing ART experience strained relationships with their partners (
      • Borneskog C.
      • Lampic C.
      • Sydsj G.
      • Bladh M.
      • Svanberg A.S.
      Relationship satisfaction in lesbian and heterosexual couples before and after assisted reproduction: A longitudinal follow-up study.
      ).
      Numerous studies also find that pregnant sexual minority women experience prejudice and homophobia from health care providers and medical staff during pregnancy and childbirth, including disparaging comments, lack of respect, and heteronormative language insensitive to the needs of diverse families (e.g., assuming the co-parent is a father rather than a mother) (
      • Dahl B.
      • Margrethe Fylkesnes A.
      • Sørlie V.
      • Malterud K.
      Lesbian women’s experiences with healthcare providers in the birthing context: A meta-ethnography.
      ,
      • Hammond C.
      Exploring same sex couples’ experiences of maternity care.
      ,
      • Harvey S.M.
      • Carr C.
      • Bernheine S.
      Lesbian mothers: Health care experiences.
      ,
      • Larsson A.K.
      • Dykes A.K.
      Care during pregnancy and childbirth in Sweden: Perspectives of lesbian women.
      ,
      • Lee E.
      • Taylor J.
      • Raitt F.
      “It’s not me, it’s them”: How lesbian women make sense of negative experiences of maternity care: A hermeneutic study.
      ). Sexual minority women also report being worried about societal-based discrimination and stigma harming their families (
      • Gartrell N.
      • Hamilton J.
      • Banks A.
      • Mosbacher D.
      • Reed N.
      • Sparks C.H.
      • Bishop H.
      The National Lesbian Family Study: Interviews with prospective mothers.
      ).
      Overall, these studies suggest that sexual minority women may experience greater stress and more barriers to care during pregnancy, which may translate to adverse health outcomes for the mother and the child. Indeed, early studies using convenience samples found that sexual minority women may be more likely to have perinatal depression compared with heterosexual women (
      • Maccio E.M.
      • Pangburn J.A.
      The case for investigating postpartum depression in lesbians and bisexual women.
      ,
      • Ross L.E.
      • Steele L.
      • Goldfinger C.
      • Strike C.
      Perinatal depressive symptomatology among lesbian and bisexual women.
      ,
      • Ross L.E.
      • Siegel A.
      • Dobinson C.
      • Epstein R.
      • Steele L.S.
      “I Don’t Want to Turn Totally Invisible”: Mental health, stressors, and supports among bisexual women during the perinatal period.
      ,
      • Trettin S.
      • Moses-Kolko E.L.
      • Wisner K.L.
      Lesbian perinatal depression and the heterosexism that affects knowledge about this minority population.
      ). One recent study using nationally representative data from the National Survey of Family Growth found that sexual minority women were more likely to have miscarriages, pregnancies ending in stillbirth, and low birthweight infants—possibly as a result of psychosocial stressors before and during pregnancy (
      • Everett B.G.
      • Kominiarek M.A.
      • Mollborn S.
      • Adkins D.E.
      • Hughes T.L.
      Sexual orientation disparities in pregnancy and infant outcomes.
      ). No research that we are aware of, however, has comprehensively examined access to care, health status, and health behaviors among sexual minority women during pregnancy using representative data. This study builds on previous research and is one of the first to use population-based data to compare an array of health outcomes between pregnant sexual minority women and pregnant heterosexual women.

      Methods

      Data Source

      This study uses data from the 2014–2016 Behavioral Risk Factor Surveillance System (BRFSS), a cross-sectional and nationally representative telephone survey of the civilian, noninstitutionalized population aged 18 years and older. The BRFSS is conducted annually by the Centers for Disease Control and Prevention in conjunction with state health departments in all 50 states and the District of Columbia. Approximately 450,000 adults are randomly selected for the survey every year and asked a core set of questions, including information about demographic and socioeconomic characteristics, health conditions, health care access, and health services use. Additionally, states have the option to add BRFSS-supported modules on specific topics, or states can develop and include their own questions in their statewide BRFSS. The median state-level response rate was 47.1% in 2016 (ranging from 30.7% in Louisiana to 65.0% in Wyoming) (
      Centers for Disease Control and Prevention
      Behavioral Risk Factor Surveillance System: 2016 Summary Data Quality Report.
      ).

      Study Sample

      Currently, the BRFSS core questionnaire does not ascertain sexual orientation, but several states have independently added sexual orientation questions to their specific BRFSS surveys in previous years (
      • Conron K.J.
      • Mimiaga M.J.
      • Landers S.J.
      A population-based study of sexual orientation identity and gender differences in adult health.
      ,
      • Dilley J.A.
      • Simmons K.W.
      • Boysun M.J.
      • Pizacani B.A.
      • Stark M.J.
      Demonstrating the importance and feasibility of including sexual orientation in public health surveys: Health disparities in the Pacific Northwest.
      ,
      • Sell R.
      • Holliday M.
      Sexual orientation data collection policy in the United States: Public health malpractice.
      ). State-added questions are not submitted to the Centers for Disease Control and Prevention, so analyzing BRFSS data on sexual minority populations across state borders previously required permission from each individual state (
      • Blosnich J.R.
      • Farmer G.W.
      • Lee J.G.L.
      • Silenzio V.M.B.
      • Bowen D.J.
      Health inequalities among sexual minority adults.
      ). Starting in 2014, the BRFSS offered states an optional and unified sexual orientation module, and the following 31 states and Guam added a sexual orientation question to their statewide BRFSS surveys in 2014, 2015, and/or 2016: California, Colorado, Connecticut, Delaware, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Mississippi, Missouri, Montana, Nevada, New York, Ohio, Pennsylvania, Rhode Island, Texas, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.
      In the sexual orientation module, respondents were asked which of the following categories best represents how they identify themselves: straight, lesbian or gay, or bisexual. Although the BRFSS does include information on transgender status, we chose to focus this analysis on differences by sexual orientation among cisgender women. Our final sample included 3,901 reproductive-age cisgender women between 18 and 44 years of age who identified as lesbian or bisexual and 63,827 reproductive-age cisgender women between 18 and 44 years of age who identified as heterosexual. Our analysis excluded reproductive-age women indicating their sexual orientation as something else (n = 311), respondents who did not know the answer (n = 678), and respondents who refused to answer (n = 896) the sexual orientation question. Previous research on nonresponse to a related sexual orientation question found higher nonresponse rates among racial and ethnic minorities (
      • Kim H.J.
      • Fredriksen-Goldsen K.I.
      Nonresponse to a question on self-identified sexual orientation in a public health survey and its relationship to race and ethnicity.
      ), but nonresponse to sexual orientation was similar to other sensitive questions, such as body weight (
      • VanKim N.A.
      • Padilla J.L.
      • Lee J.G.L.
      • Goldstein A.O.
      Adding sexual orientation questions to statewide public health surveillance: New Mexico’s experience.
      ). All analyses were examined by sexual minority status and pregnancy status, which was identified when the respondent said yes to the following question: “To your knowledge, are you now pregnant?” Unfortunately, data on pregnancy intention, reproductive history, and contraception use were not available in the main BRFSS questionnaire at the time of this study (
      • Boulet S.L.
      • Warner L.
      • Adamski A.
      • Smith R.A.
      • Burley K.
      • Grigorescu V.
      Behavioral Risk Factor Surveillance System state-added questions: Leveraging an existing surveillance system to improve knowledge of women’s reproductive health.
      ).

      Health Care Access Outcomes

      We examined outcomes that represent the wide spectrum of health, access to care, and health risk factors that impact adverse pregnancy outcomes. First, we examined differences in five dimensions of health care access and health services use ascertained in the BRFSS questionnaire. No health insurance was indicated when the participant said they did not have health care coverage at the time of the survey, including health insurance, prepaid plans such as health maintenance organizations, or governmental plans such as Medicare, Medicaid, TRICARE, or Indian Health Service. No usual source of care was indicated when a participant stated they currently did not have one specific person they think of as their personal doctor or health care provider. Unmet medical care need owing to cost was indicated when the participant recalled a time in the past 12 months when they needed to see a doctor but could not afford to because of cost. No routine checkup and no flu shot were assigned when the participant stated that it had been more than 1 year since they last visited a doctor for a routine checkup or received a flu vaccine.

      Health Status and Health Behavior Outcomes

      The next set of outcomes measured different dimensions of health, which included frequent mental distress (i.e., mental health—which includes stress, depression, and problems with emotions—was “not good” 14 days or more in the previous 30 days) and diagnosed depression (i.e., the respondent was ever told they had depression, major depression, dysthymia, or minor depression). Three measures of physical and functional health were also measured: self-rated poor/fair health (vs. excellent, very good, or good health), poor physical health days (i.e., physical health—which includes physical illness and injury—was “not good” 14 days or more in the previous 30 days), and activity limitations owing to health problems (i.e., the respondent was limited in any way because of physical, mental, or emotional problems). We also considered whether the respondent was ever told by a physician, nurse, or other health professional that they had any of the following health conditions: cardiovascular disease (including angina, coronary heart disease, heart attack, and stroke), cancer (including skin cancer), arthritis (including rheumatoid arthritis, gout, lupus, or fibromyalgia), asthma, and/or diabetes (not including gestational diabetes). Finally, we compared the prevalence of different risk factors for adverse pregnancy outcomes: cigarette smoking (i.e., currently smoking cigarettes some days or every day), consumption of any alcoholic beverages in the previous 30 days, and binge drinking in the previous 30 days (i.e., drinking four or more drinks for women on one occasion).

      Statistical Analysis

      We used descriptive statistics to characterize the study sample, and we estimated the prevalence of each outcome by sexual minority status and pregnancy status. Next, we estimated multivariable logistic regression models to compare the odds of each outcome between sexual minority women and their heterosexual peers by pregnancy status while controlling for demographic and socioeconomic characteristics. Then, we repeated logistic regression analyses to compare each outcome between pregnant and nonpregnant women by sexual minority status. Finally, we estimated logistic regression models using the complete sample and included interactions between pregnancy status and sexual minority status to determine whether any differences were wider or narrower for pregnant sexual minority women compared with other women. All logistic regression models controlled for age in years (18–24, 25–29, 30–34, 35–39, and 40–44), race and ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other/multiple races), relationship status (married or living with a partner; divorced, separated, or widowed; never married), the presence of children in the household, educational attainment (less than high school, high school graduate, some college, and college graduate), household income in dollars (0–9,999, 10,000–19,999, 20,000–34,999, 35,000–49,999, 50,000–74,999, and ≥75000), language of interview (English vs. non-English), state of residence, and survey year. We included indicators when data were missing for each covariate. Results from the logistic regression models are presented as adjusted odds ratios (ORs) with 95% CIs. We conducted all analyses in Stata version 14 using survey weights and the svy command to adjust standard errors for the complex survey design of the BRFSS (
      • StataCorp
      ). This study was deemed exempt from review by the Vanderbilt University Institutional Review Board because data were obtained from de-identified, publicly available, and secondary sources.

      Results

      Sociodemographic Characteristics of the Study Sample

      After applying survey weights, approximately 4.2% of reproductive-age heterosexual women and 3.4% of reproductive-age sexual minority women were pregnant in the 2014–2016 BRFSS (data not shown). Approximately 5.3% of reproductive-age women who were pregnant in the 2014–2016 BRFSS considered themselves lesbian or bisexual; 94.7% considered themselves heterosexual (data not shown). Table 1 presents the sociodemographic characteristics of reproductive-age women by pregnancy and sexual minority status. Most pregnant sexual minority women (91.3%) were bisexual, and fewer (8.7%) were lesbian. Compared with pregnant heterosexual women, pregnant sexual minority women tended to be younger (approximately 50% were 18–24 years of age), White, and with lower levels of educational attainment (only 12% had a college degree). Pregnant sexual minority women were also less likely to be married or living with a partner (42.5%) compared with pregnant heterosexual women (67.8%), and they were less likely to have a child in the household (55.4% vs. 67.9%).
      Table 1Characteristics of Reproductive-Age Women by Pregnancy and Sexual Minority Status
      PregnantNonpregnant
      HeterosexualSexual MinorityHeterosexualSexual Minority
      (n = 2,433)(n = 117)(n = 61,394)(n = 3,784)
      Sexual orientation
       Heterosexual100.00.0100.00.0
       Lesbian0.08.70.024.3
       Bisexual0.091.30.075.7
      Age, years
       18–2427.549.826.143.2
       25–2926.231.915.219.6
       30–3429.214.519.816.4
       35–3912.53.118.29.8
       40–444.70.820.811.0
      Race/ethnicity
       Non-Hispanic White55.575.257.859.2
       Non-Hispanic Black12.113.413.615.0
       Hispanic23.76.118.614.5
       Non-Hispanic other8.24.48.910.3
       Missing data0.70.91.11.0
      Relationship status
       Married or living with a partner67.842.550.631.7
       Separated/divorced/widowed4.85.610.310.0
       Never married27.251.838.857.9
       Missing data0.20.00.30.5
      Children present in the household
       No32.044.732.750.1
       Yes67.955.467.049.6
       Missing data0.10.00.30.3
      Educational attainment
       Less than high school12.219.311.914.5
       High school graduate26.444.424.527.5
       Some college30.023.634.338.7
       ≥Bachelor's degree31.312.329.219.2
       Missing data0.00.40.10.1
      Household income (US$)
       0–9,9995.77.46.29.2
       10,000–19,99913.617.111.714.2
       20,000–34,99916.824.416.820.2
       35,000–49,9999.69.011.512.0
       50,000–74,99914.23.712.39.5
       ≥75,00027.020.128.017.3
       Missing data13.118.513.417.6
      Interview conducted in English
       Yes91.097.392.597.8
       No9.02.77.52.2
      Note. Data are from the 2014–2016 Behavioral Risk Factor Surveillance System (BRFSS), women aged 18–44 years.
      All estimates are weighted percentages (%).
      Nonpregnant sexual minority and heterosexual women shared similar patterns, with some notable exceptions. Most nonpregnant sexual minority women of reproductive age were bisexual (75.7%), but approximately one-quarter (24.3%) were lesbian. Compared with nonpregnant heterosexual women, nonpregnant sexual minority women were younger, less likely to be married or living with a partner, and less likely to have a child in the household. Patterns in race/ethnicity and educational attainment were relatively similar between nonpregnant heterosexual women and nonpregnant sexual minority women. However, nonpregnant sexual minority women were less likely to have a college degree (19.2%) compared with their heterosexual peers (29.2%).

      Health Outcomes by Pregnancy and Sexual Minority Status

      Table 2 presents prevalence estimates and multivariable logistic regression results comparing health care access and health risk factors for reproductive-age women by pregnancy and sexual minority status. Approximately 10% of pregnant sexual minority women were uninsured, and nearly one-third had unmet medical care needs owing to cost (26.8%), no usual source of care (32.2%), and no routine checkup (33.9%). Less than one-tenth of pregnant heterosexual women were uninsured (8.2%), and less than one-third had unmet medical care needs owing to cost (15.8%), no usual source of care (26.5%), and no routine checkup (28.4%). After controlling for sociodemographic characteristics, there were no differences in uninsurance, no usual source of care, and no routine checkup between pregnant sexual minority women and pregnant heterosexual women, but pregnant sexual minority women were more likely to report unmet medical care needs owing to cost (OR, 2.56; 95% CI, 1.26–5.21) and no flu shot in the prior year (OR, 2.11; 95% CI, 1.12–3.97) compared with pregnant heterosexual women. Meanwhile, nonpregnant sexual minority women were more likely to have unmet medical care needs owing to cost, no usual source of care, and no routine checkup in the prior year compared with nonpregnant heterosexual women.
      Table 2Health Care Access and Health Risk Factors for Reproductive-Age Women by Pregnancy and Sexual Minority Status
      PregnantNonpregnant
      Heterosexual, %Sexual Minority, %Adjusted OR (95% CI)p ValueHeterosexual, %Sexual Minority, %Adjusted OR (95% CI)p Value
      Health care access and use
       No current health insurance8.29.50.81 (0.29–2.22).6814.415.31.10 (0.92–1.31).32
       Unmet medical care needs owing to cost in prior year15.826.82.56 (1.26–5.21).0116.926.01.70 (1.46–1.97)<.001
       No current usual source of care26.532.21.36 (0.73–2.52).3429.535.51.18 (1.04–1.34).008
       No routine checkup in prior year28.433.91.21 (0.63–2.32).5732.436.81.21 (1.07–1.37).003
       No flu shot in prior year55.877.12.11 (1.12–3.97).0265.270.51.27 (1.00–1.28).06
      Mental health
       Frequent mental distress, past 30 days9.428.23.13 (1.45–6.75).00414.329.22.06 (1.80–2.36)<.001
       Depression diagnosis, in lifetime16.444.82.85 (1.47–5.52).00220.945.73.02 (2.67–3.42)<.001
      Physical health
       Poor/fair health7.220.33.50 (1.46–8.43).00511.919.11.76 (1.49–2.08)<.001
       Poor physical health days, past 30 days6.619.83.59 (1.51–8.49).0048.213.41.65 (1.36–2.00)<.001
       Current activity limitations10.538.85.92 (2.82–12.44)<.00112.624.82.17 (1.84–2.57)<.001
       Any chronic conditions, in lifetime16.029.52.09 (1.11–3.93).0223.834.61.71 (1.50–1.94)<.001
      Health risks
       Currently smokes every day4.627.55.63 (2.49–12.72)<.00111.921.21.82 (1.55–2.14)<.001
       Currently smokes some days3.712.83.20 (1.05–9.75).044.68.71.74 (1.43–2.12)<.001
       Any alcohol consumption, past 30 days9.621.62.93 (1.34–6.41).00754.563.91.63 (1.43–1.86)<.001
       Binge drinking, past 30 days2.79.63.48 (1.13–10.73).0317.729.01.69 (1.47–1.93)<.001
      Note. Data are from the 2014–2016 Behavioral Risk Factor Surveillance System (BRFSS), women aged 18–44 years. Adjusted odds ratios are from logistic regression models controlling for age, race/ethnicity, educational attainment, presence of children in the household, household income, language of interview, state, and survey year.
      Table 2 also presents comparisons for health status and health risks by pregnancy and sexual minority status. More than one-quarter of pregnant sexual minority women (28.2%) were currently living with frequent mental distress, and nearly one-half (44.8%) indicated they were diagnosed with depression at some point in the past. After controlling for sociodemographic factors, pregnant sexual minority women were more likely to report frequent mental distress (OR, 3.13; 95% CI, 1.45–6.75), a depression diagnosis (OR, 2.85; 95% CI, 1.47–5.52), poor/fair health (OR, 3.50; 95% CI, 1.46–8.43), poor physical health days (OR, 3.59; 95% CI, 1.51–8.49), activity limitations (OR, 5.92; 95% CI, 2.82–12.44), and at least one chronic health condition (OR, 2.09; 95% CI, 1.11–3.93) compared with pregnant heterosexual women. Pregnant sexual minority women were also more likely to report smoking every (OR, 5.63; 95% CI, 2.49–12.72) or some days (OR, 3.20; 95% CI, 1.05–9.75), any alcohol consumption (OR, 2.93; 95% CI, 1.34–6.41), and binge drinking (OR, 3.48; 95% CI, 1.13–10.73) in the prior 30 days compared with pregnant heterosexual women after controlling for sociodemographic characteristics. Adverse health outcomes and health behaviors were also prevalent in nonpregnant sexual minority women. Compared with nonpregnant heterosexual women, nonpregnant sexual minority women were more likely to report frequent mental distress, depression, poor/fair health, poor physical health days, activity limitations, chronic conditions, cigarette smoking, and recent episodes of binge drinking.
      Table 3 presents the ORs comparing health care access and health risk factors between pregnant and nonpregnant women by sexual minority status. Pregnant heterosexual women generally reported lower odds of adverse health outcomes compared with nonpregnant heterosexual women. After controlling for sociodemographic characteristics, pregnant heterosexual women were less likely to report no health insurance, no usual source of care, no routine checkup, no flu shot, mental distress, depression, poor/fair health, chronic conditions, smoking every day, and alcohol consumption compared with nonpregnant heterosexual women. Differences between pregnant and nonpregnant women were not significant for most outcomes examined among sexual minority women. However, after controlling for sociodemographic covariates, pregnant sexual minority women were marginally more likely to report activity limitations (OR, 2.19; 95% CI, 0.91–5.24) and less likely to report any drinking (OR, 0.16; 95% CI, 0.08–0.34) and binge drinking (OR, 0.28; 95% CI, 0.10–0.79) in the past 30 days compared with nonpregnant sexual minority women.
      Table 3Odds Ratios Comparing Health Care Access and Health Risk Factors Between Pregnant and Nonpregnant Women by Sexual Minority Status
      Heterosexual WomenSexual Minority Women
      Pregnant vs NonpregnantPregnant vs Nonpregnant
      Adjusted OR (95% CI)p ValueAdjusted OR (95% CI)p Value
      Health care access and use
       No current health insurance0.37 (0.27–0.50)<.0010.44 (0.16–1.21).11
       Unmet medical care needs owing to cost in prior year0.90 (0.72–1.12).341.07 (0.56–2.05).84
       No current usual source of care0.74 (0.62–0.87)<.0010.89 (0.48–1.66).72
       No routine checkup in prior year0.76 (0.65–0.90).0010.80 (0.44–1.48).48
       No flu shot in prior year0.68 (0.59–0.79)<.0011.28 (0.67–2.42).45
      Mental health
       Frequent mental distress, past 30 days0.67 (0.52–0.86).0010.83 (0.43–1.60).59
       Depression diagnosis, in lifetime0.81 (0.67–0.99).040.84 (0.46–1.51).56
      Physical health
       Poor/fair health0.65 (0.47–0.90).011.15 (0.53–2.51).72
       Poor physical health days, past 30 days0.95 (0.71–1.27).731.98 (0.86–4.53).11
       Current activity limitations1.01 (0.80–1.27).962.19 (0.91–5.24).08
       Any chronic conditions, in lifetime0.74 (0.62–0.89).0010.86 (0.43–1.72).68
      Health risks
       Currently smokes every day0.38 (0.27–0.52)<.0011.24 (0.64–2.42).52
       Currently smokes some days0.86 (0.61–1.22).41.54 (0.57–4.17).40
       Any alcohol consumption, past 30 days0.07 (0.05–0.09)<.0010.16 (0.08–0.34)<.001
       Binge drinking, past 30 days0.12 (0.08–0.19)<.0010.28 (0.10–0.79).02
      Note. Data are from the 2014–2016 Behavioral Risk Factor Surveillance System (BRFSS), women aged 18–44 years. Adjusted odds ratios are from logistic regression models controlling for age, race/ethnicity, educational attainment, presence of children in the household, household income, language of interview, state, and survey year.
      Table 4 presents logistic regression results on health care access and health risk factors for reproductive-age women with an interaction between sexual minority status and pregnancy status. Results in Table 4 (column A) suggest substantial disparities in health care access, mental health, physical health, and health risks for sexual minorities compared with heterosexuals. Compared with nonpregnant women, pregnant women (Table 4, column B) generally report fewer barriers to care, better mental health and self-rated health, and fewer health risks. The interactions presented in Table 4 (column A × B) indicate that pregnant sexual minority women may be more likely to have no flu shot (OR, 1.99; 95% CI, 1.04–3.81) and be current every day smokers (OR, 3.00; 95% CI, 1.41–6.39) compared with other subgroups of women after controlling for sociodemographic characteristics.
      Table 4Logistic Regression Results on Health Care Access and Health Risk Factors for Reproductive-Age Women with an Interaction between Sexual Minority Status and Pregnancy Status
      (A)(B)(A × B)
      Sexual MinorityPregnantSexual Minority
      vs. Heterosexualvs. Nonpregnant× Pregnant
      Adjusted OR (95% CI)p ValueAdjusted OR (95% CI)p ValueAdjusted OR (95% CI)p Value
      Health care access and use
       No current health insurance1.09 (0.91–1.31).330.37 (0.27–0.51)<.0011.32 (0.46–3.81).61
       Unmet medical care needs owing to cost in prior year1.69 (1.46–1.97)<.0010.90 (0.72–1.12).331.14 (0.58–2.25).70
       No current usual source of care1.18 (1.05–1.34).010.73 (0.62–0.87)<.0011.16 (0.61–2.21).65
       No routine checkup in prior year1.21 (1.07–1.37).0030.76 (0.65–0.89).0011.04 (0.56–1.94).90
       No flu shot in prior year1.13 (0.99–1.28).060.68 (0.59–0.79)<.0011.99 (1.04–3.81).04
      Mental health
       Frequent mental distress, past 30 days2.06 (1.80–2.36)<.0010.66 (0.52–0.85).0011.36 (0.67–2.72).39
       Depression diagnosis, in lifetime3.00 (2.66–3.40)<.0010.81 (0.67–0.99).041.09 (0.58–2.04).80
      Physical health
       Poor/fair health1.76 (1.49–2.07)<.0010.65 (0.46–0.90).011.79 (0.76–4.19).18
       Poor physical health days, past 30 days1.65 (1.36–2.00)<.0010.95 (0.71–1.27).711.87 (0.79–4.42).15
       Current activity limitations2.17 (1.84–2.56)<.0011.00 (0.79–1.25).982.24 (0.97–5.18).06
       Any chronic conditions, in lifetime1.71 (1.51–1.94)<.0010.74 (0.62–0.89).0011.16 (0.59–2.29).67
      Health risks
       Currently smokes every day1.81 (1.55–2.13)<.0010.38 (0.28–0.52)<.0013.00 (1.41–6.39).004
       Currently smokes some days1.74 (1.43–2.12)<.0010.85 (0.60–1.21).371.80 (0.63–5.13).27
       Any alcohol consumption, past 30 days1.63 (1.43–1.85)<.0010.07 (0.05–0.09)<.0012.09 (0.92–4.78).08
       Binge drinking, past 30 days1.69 (1.47–1.93)<.0010.12 (0.08–0.19)<.0011.99 (0.61–6.57).26
      Note. Data are from the 2014–2016 Behavioral Risk Factor Surveillance System (BRFSS), women aged 18–44 years. Adjusted odds ratios are from logistic regression models controlling for age, race/ethnicity, educational attainment, presence of children in the household, household income, language of interview, state, and survey year.

      Discussion

      Health issues related to pregnancy among sexual minority women have been understudied despite sexual minority women's increased risk for adverse health outcomes and experiences during pregnancy. Not only can pregnancy be a stressful life event, but sexual minority women may also experience discrimination and stigma that heighten stress levels during pregnancy. This analysis offers one of the first examinations of health care access, mental and physical health, and health behaviors by sexual minority and pregnancy status among a representative sample of reproductive-age women in 31 states. Given the large body of research that has documented health disparities in sexual minorities (
      • Blosnich J.R.
      • Farmer G.W.
      • Lee J.G.L.
      • Silenzio V.M.B.
      • Bowen D.J.
      Health inequalities among sexual minority adults.
      ,
      • Conron K.J.
      • Mimiaga M.J.
      • Landers S.J.
      A population-based study of sexual orientation identity and gender differences in adult health.
      ,
      • Gonzales G.
      • Henning-Smith C.
      Health disparities by sexual orientation: Results and implications from the Behavioral Risk Factor Surveillance System.
      ,
      • Gonzales G.
      • Przedworski J.
      • Henning-Smith C.
      Comparison of health and health risk factors between lesbian, gay, and bisexual adults and heterosexual adults in the United States: Results from the National Health Interview Survey.
      ,
      Institute of Medicine
      The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding.
      ), it is unsurprising that we found a higher prevalence of health problems among reproductive-age sexual minority women compared with heterosexual women, which may have translated into a higher prevalence of these problems among pregnant sexual minority women.

      Implications for Policy and/or Practice

      Nearly 4 million women give birth in the United States each year (
      • Martin J.A.
      • Hamilton B.E.
      • Osterman M.J.K.S.
      • Driscoll A.K.
      • Drake P.
      Births: Final Data for 2016.
      ). If 5.3% are sexual minority women (i.e., lesbian or bisexual), this translates into more than 210,000 births to sexual minority women annually. This study suggests that sexual minority women are a population that may have enhanced health care needs before, during, and after pregnancy. Our study found that nonpregnant sexual minority women reported poorer access to care among several dimensions compared with nonpregnant heterosexual women, but there were fewer differences in access to care for sexual minorities among pregnant women. This finding may be partly due to higher income eligibility thresholds for Medicaid during pregnancy in many states (
      • The Henry J. Kaiser Family Foundation
      Where are states today? Medicaid and CHIP eligibility levels for children, pregnant women, and adults.
      ). Pregnant women—including sexual minorities—who are able to obtain Medicaid coverage may have better access to medical care. Additionally, the vast majority of women do seek prenatal care during pregnancy (
      • Martin J.A.
      • Hamilton B.E.
      • Osterman M.J.K.S.
      • Driscoll A.K.
      • Drake P.
      Births: Final Data for 2016.
      ), making it more likely that this group would report a usual source of care and a routine checkup. However, pregnant sexual minority women still reported substantially higher rates of cost-related barriers to needed medical care compared with pregnant heterosexual women. Addressing high health care costs may help to narrow these financial-related gaps in health care access.
      Meanwhile, the higher prevalence of poor mental health among sexual minority women is of concern. There has been increasing recognition that mental health issues—such as depression—that manifest before and during pregnancy can have negative effects on the mother and fetus (
      • Field T.
      • Diego M.
      • Hernandez-Reif M.
      Prenatal depression effects on the fetus and newborn: A review.
      ). Additionally, women who experience mental health problems during pregnancy are more likely to have miscarriages, preterm births, and low birthweight infants (
      • Schetter C.D.
      Psychological science on pregnancy: Stress processes, biopsychosocial models, and emerging research issues.
      ,
      • Schetter C.D.
      • Tanner T.
      Anxiety, depression and stress in pregnancy: Implications for mothers, children, research, and practice.
      ) and to experience postpartum mood disorders (
      • Howard L.M.
      • Molyneaux E.
      • Dennis C.L.
      • Rochat T.
      • Stein A.
      • Milgrom J.
      Non-psychotic mental disorders in the perinatal period.
      ). Despite efforts to improve care for such disorders, access to clinicians equipped to care for women with mood disorders in the peripartum period remains a challenge (
      • Howard L.M.
      • Molyneaux E.
      • Dennis C.L.
      • Rochat T.
      • Stein A.
      • Milgrom J.
      Non-psychotic mental disorders in the perinatal period.
      ). Future research and public health initiatives should identify best practices, ranging from culturally competent clinical interventions to community-based programs providing psychosocial resources, for addressing mental health among reproductive-age sexual minority women.
      This analysis also found that health behaviors associated with adverse outcomes during pregnancy were much more common among pregnant sexual minority women compared with pregnant heterosexual women. Pregnant sexual minority women had greater odds of alcohol consumption, binge drinking, and cigarette smoking compared with pregnant heterosexual women. Alcohol consumption during pregnancy is associated with a number of negative outcomes for the fetus, collectively termed fetal alcohol spectrum disorders (
      • Sokol R.J.
      • Delaney-Black V.
      • Nordstrom B.
      Fetal alcohol spectrum disorder.
      ). Smoking during pregnancy is associated with well-documented risks for both the woman and the fetus. For women, it increases the risks of deep vein thrombosis and pulmonary embolism, as well as other serious conditions (
      • Roelands J.
      • Jamison M.G.
      • Lyerly A.D.
      • James A.H.
      Consequences of smoking during pregnancy on maternal health.
      ). Among other risks, babies born to women who smoked during pregnancy are more likely to be born preterm and at low birthweight, and to experience sudden infant death syndrome (
      • American College of Obstetricians and Gynecologists
      ACOG Committee Opinion on Smoking Cessation During Pregnancy.
      ,
      • Dietz P.M.
      • England L.J.
      • Shapiro-Mendoza C.K.
      • Tong V.T.
      • Farr S.L.
      • Callaghan W.M.
      Infant morbidity and mortality attributable to prenatal smoking in the U.S.
      ).
      Finally, previous research suggests that some sexual minority women may be at risk for unintended pregnancy (
      • Everett B.G.
      • McCabe K.F.
      • Hughes T.L.
      Unintended pregnancy, depression, and hazardous drinking in a community-based sample of sexual minority women.
      ,
      • Hartnett C.S.
      • Lindley L.L.
      • Walsemann K.M.
      Congruence across sexual orientation dimensions and risk for unintended pregnancy among adult U.S. women.
      ). If pregnancies among sexual minority women are more likely to be unintended, it is possible that part of the increased risk for alcohol use and smoking could be explained by later pregnancy recognition and persistence of these behaviors into early pregnancy (
      • Dott M.
      • Rasmussen S.A.
      • Hogue C.J.
      • Reefhuis J.
      Association between pregnancy intention and reproductive health related behaviors before and after pregnancy recognition, National Birth Defects Prevention Study, 1997-2002.
      ,
      • Joyce T.E.D.
      • Kaestner R.
      • Korenman S.
      On the validity of retrospective assessments of pregnancy intention.
      ). It is also possible that clinicians are less likely to ask sexual minority women about plans for becoming pregnant and to discuss health behaviors that may be harmful during pregnancy—either owing to assumptions about whether sexual minority women will become pregnant or owing to limited health care access for nonpregnant sexual minority women. Moreover, current strategies and interventions to encourage tobacco and alcohol cessation during pregnancy may not meet the needs of sexual minority women, particularly among women who know that they are pregnant and have initiated prenatal care. Much more research and programs are needed to ensure that perinatal care is inclusive of diverse families and sexual orientations.

      Limitations

      There were several limitations to using the 2014–2016 BRFSS for this study. First, all responses to the BRFSS were self-reported, which can lead to recall and response bias when describing health conditions and sociodemographic characteristics. Additionally, reporting sexual orientation may suffer from selection bias. Our sample of sexual minority adults only includes reproductive-age women who were comfortable disclosing their sexual orientation to BRFSS interviewers. Thus, our study may be missing sexual minorities from vulnerable subgroups not comfortable disclosing their sexual orientation. Also missing from this study were LGB adults in the states not choosing to ascertain sexual orientation. Therefore, our results may not be generalizable to all sexual minority women, because our study only included data from 31 states. States in the southeastern United States were especially underrepresented. We hope that questions on sexual orientation will be added to the core BRFSS questionnaire in the near future.
      This study would have benefited from additional data missing in the BRFSS. For example, the BRFSS does not measure other dimensions of sexual orientation, including sexual behavior or sexual attraction. Thus, our study does not consider individuals who are sexually active with or attracted to people of the same sex but do not identify as lesbian, gay, or bisexual. Health outcomes may vary for women whose sexual orientation identities and attractions are not congruent (
      • Hartnett C.S.
      • Lindley L.L.
      • Walsemann K.M.
      Congruence across sexual orientation dimensions and risk for unintended pregnancy among adult U.S. women.
      ). Furthermore, the sample size of sexual minority women identified in the survey was also relatively small. Thus, although there may be important differences between subgroups (e.g., lesbian vs. bisexual women), we did not have sufficient sample size to analyze these distinctions. The BRFSS main questionnaire also does not contain information on pregnancy intention, reproductive history, or conception date, which can be related to the timing of pregnancy recognition as well as risk behaviors. There is also a lack of information on the gestational age of the pregnancy at the time of the interview, which would be helpful information in interpreting some of the outcomes. For example, women in early pregnancy may have consumed alcohol in the last 30 days, but not since discovering the pregnancy.
      Finally, the BRFSS is a cross-sectional survey and cannot definitively establish the causal pathways for the observed associations between sexual orientation and health, because cross-sectional studies are prone to omitted variable bias. Missing and unmeasured variables—such as exposure to discrimination or nondisclosure of sexual orientation to family, friends, and providers—may provide alternative explanations for the relationship between sexual orientation and health risk factors during pregnancy. Future research should continue to explore the underlying causes of adverse health and health behaviors during the perinatal period for sexual minority women. Ongoing surveillance systems, such as the Pregnancy Risk Assessment Monitoring System, should incorporate sexual orientation data collection into ongoing assessments. Having more data will facilitate broader and more thorough research on this vulnerable population.

      Conclusions

      This study is one of the first to examine the health of reproductive-age women by sexual minority and pregnancy status using population-based data. We found substantial disparities in health, access to care, and health behaviors for reproductive-age sexual minority women. This research highlights the need for more targeted programs and clinical interventions to improve health in sexual minority women before, during, and after pregnancy. Ongoing assessments should identify best practices that are culturally competent and effective at improving behavioral risk factors in sexual minority women. Additionally, providers should create welcoming environments that encourage regular and routine checkups for sexual minority women, especially during pregnancy. Our study provides important baseline data for monitoring progress toward achieving health equity for sexual minority populations.

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      Biography

      Gilbert Gonzales, PhD, MHA, is Assistant Professor, Department of Health Policy, Vanderbilt University School of Medicine. His research examines impacts of public and health policy on health, access to care, and health services use for lesbian, gay, bisexual, and transgender (LGBT) populations.
      Nicole Quinones, BA, is a student in the MPH Health Policy Program at the Vanderbilt University School of Medicine. Her research and policy interests are in sexual and reproductive health and health disparities.
      Laura Attanasio, PhD, MS, is an Assistant Professor in the Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst. Her research interests include reproductive health, childbirth care, and addressing health and health care disparities.