A healthy pregnancy and a healthy baby are the primary goals of most parents choosing to have a child. While parents may take many steps, such as using prenatal vitamins or quitting drinking alcohol or smoking, some factors influence pregnancy outcomes beyond their control.

I was awarded a large NIH grant to study how structural stigma, that is, the way that stigma and discrimination are codified into laws and policies, influence the maternal and infant health of sexual minority women (e.g., women who identify as bisexual/lesbian/queer or have same-sex attractions or relationships [SMW]). Sexual minority populations are more likely to experience discrimination at multiple levels compared to heterosexual populations, and several studies have linked stress to adverse maternal and fetal health. Little research, however, has examined how stress and the social environment may impact the obstetrical and perinatal health of SMW.

Much of the prior research focused on women in same-sex relationships accessing assisted reproductive technologies to conceive. While important, these studies systematically exclude SMW in romantic relationships with men (i.e. bisexual women partnered with men), SMW who are single, and SMW who become pregnant through sex with a male partner. In fact, my research has found that SMW, including lesbian-identified women, are more likely to describe their pregnancies as “unwanted” than heterosexual women.

In a first-of-its-kind study using nationally representative data, we documented that SMW were more likely to have preterm and low birthweight infants. We were unable, however, to identify the mechanisms that led to these worse outcomes among SMW. This finding led us to use the National Longitudinal Study of Adolescent to Adult Health, a longitudinal, probability-based US survey of middle and high school students that began in 1993 and 1994 and has followed the same students for over twenty years. Using this longitudinal data, we were able to document several disparities in perinatal and obstetrical risk factors by sexual orientation, including preconception health behaviors. These differences, however, did not explain why SMW were more likely to report preterm and lower birthweight infants.

 One factor, however, proved to be critical to pregnant SMW and their babies: the number of state policies that provide protections for lesbian, gay, and bisexual (LGB) persons. The policies we examined included same-sex marriage or civil union protections, anti-LGB discrimination policies, legal same-sex adoption, and banned employment discrimination based on sexual orientation. Indeed, state policies were so powerful in shaping SMW’s birth outcomes that in states with three or more of these policies, SMW had even better birth outcomes than their heterosexual peers despite higher rates of reporting key risk factors for adverse birth outcomes. The policies we examined included same-sex marriage or civil union protections, anti-LGB discrimination policies, legal same-sex adoption, and banned employment discrimination based on sexual orientation. We found that these policies also were associated with a lower risk of maternal hypertension, particularly for Black SMW. This finding is in line with other research that has suggested that policies that ensure equal protection for persons based on their sexual orientation may disproportionately benefit sexual minorities of color.

The results from these studies come at a critical time when the rights of women and LGBTQ populations are under attack. A record number of laws have been introduced to undermine the progress made by LGBTQ activists and introduce new forms of discrimination that ban or reduce access to health care and multiple other forms of social and economic resources. Similarly, the bodily autonomy of pregnant persons is also under unprecedented attack; the 50-year precedent of Roe v Wade was repealed in June 2022, and many bills have been introduced to restrict access in states where abortion remains legal. With colleagues, I have argued that attacks on LGTBQ populations and reproductive rights are rooted in the same ideology that seeks to maintain a system that privileges men and heterosexuality and punishes those who challenge traditional gender and sexuality-based norms. We created a measure incorporating these two forms of discrimination (structural sexism and structural LGB stigma) into a single construct called “structural heteropatriarchy.” We showed that women who live in states and counties with higher levels of structural heteropatriarchy were more likely to have preterm and low birthweight infants, even if they identified as heterosexual.

In sum, this set of studies shows that the political and social environment in which an individual lives can undermine many of the efforts pregnant people may take to ensure a healthy pregnancy. However, the results also show that policy changes can dramatically improve maternal and infant health. Moreover, these policies do not necessarily need to target pregnant people per se, but increasing the number of civil rights and social resources individuals can access may improve maternal and infant health while also likely benefitting non-pregnant citizens. That is, living in environments that foster safety and inclusion, and support an individual’s right to choose if, when, and how they become a parent, can lead to improved population health, improved maternal and infant health, and ultimately healthier future generations.

Bethany Everett is Associate Professor of Sociology and Obstetrics and Gynecology at the University of Utah and an affiliate of the Center for Sexual and Gender Minority Health Research at Columbia University. She completed her PhD at the University of Colorado at Boulder and an NIH Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Fellowship while she was an Assistant Professor at the University of Illinois-Chicago from 2012-2015. She has published over 75 peer-reviewed articles and is currently PI of an NICHD-funded R01 study on sexual orientation disparities in maternal, infant, and child health and her work focuses on the social determinants of health, particularly in the area of orientation and sexual and reproductive health. Follow her on Twitter @bethanygeverett