Lesbian Pregnancy: Care and Considerations

Abstract

The constructs and the provision of preconception and obstetrical care have historically been based on the assumption of heterosexuality, and have often excluded lesbian women. However, due to significant strides in lesbian, gay, bisexual, transgender, and queer (LGBTQ) civil rights, more lesbian women desire to create and expand their families, and lesbian parented families are increasing. This places obstetrical care providers at the forefront of the movement to build inclusive health care environments. Therefore, it is incumbent upon those of us who work in obstetrics to understand, recognize, and respect the unique cultural considerations that pertain to lesbian women and couples seeking parenthood. This review seeks to provide culturally sensitive guidance on the specific concerns and challenges lesbians face, from preconception care to postpartum care, and briefly addresses legal issues and considerations for the nonbiologic mother. The recommendations outlined here are drawn from studies of the experiences of lesbian women with pregnancy. However, the scientific literature is very limited, and there is a clear need for additional obstetrical research focused on this patient group. As professionals committed to assuring optimal outcomes for all obstetrical patients, it is crucial that we promote the inclusion of sexual minority women in our clinical practices and research endeavors.

Keywords

lesbian - pregnancy - prenatal care - nonbiologic mother - postpartum care

A “gayby boom,” a term coined to describe an increase in the number of lesbians having babies, was first noticed almost 30 years ago.[1] Since then, there has been significant progress in legal protections for lesbian parents and greater access to health care resources for becoming pregnant. Therefore, more lesbians are choosing to become parents. Recent estimates indicate that up to 49% of lesbian and bisexual women have had a child, through prior relationships with opposite-sex partners, assisted reproduction, or adoption.[2] Given the increasing prevalence of lesbians who are parents, health care providers need to be prepared to provide well-informed obstetrical care to this patient population. In recognition of this imperative, the American College of Obstetrics and Gynecology not only endorses quality care and equitable treatment for all women regardless of sexual orientation but also calls on health care providers to become more aware of the particular challenges faced by lesbian and bisexual women and their families.[3]

While national organizations call for the provision of culturally competent care for sexual-minority patients, the data to inform this care are limited. Most obstetrical and midwifery textbooks do not include a discussion of prenatal care specifically for lesbian patients. Moreover, the few existing research studies that evaluate the obstetrical needs of lesbian patients all have small sample sizes and are not ethnically diverse. Also, most of these studies were published more than 10 years ago,[4] reviewed in the study of McManus et al.[5] Still, we do have some useful information on concerns specific to lesbians seeking reproductive health services. In 2007, Spidsberg interviewed lesbians about their obstetrical experiences and reported that they were concerned with finding an accepting health care environment where they could be open with their sexual identities and reported encounters with anxious and uncomfortable providers.[6] Another study pointed out that individuals felt that innate heterosexist assumptions from healthcare providers conveyed to the lesbian couple that they were not recognized as “normal” families and signaled that the nonpregnant partner was not viewed as a real parent.[7] This leads to the following question: Are we, as a specialty and as individual practitioners, really facilitating the optimal pregnancy experience for all of our patients?

The aim of this article is to arm obstetrical and midwifery caregivers with best practices for providing culturally competent care for this patient group. This article attempts a broad review of lesbian pregnancy care; readers must understand that not all issues may be addressed and that not all lesbian women are represented. The key to providing culturally competent care is to have open communication with individual patients and to continue learning, networking, and expanding your outlook to care for an ever-changing community. As described in this article, lesbians face several challenges on their path to parenthood. Their perseverance through these challenges illustrates that the decision to become a parent is profound and the desire to be a parent runs deep. Obstetricians and midwives are uniquely positioned to assure an equitable and inclusive experience for lesbian patients as they navigate these processes.

Creating a Culturally Competent Obstetrical Practice

An inclusive and welcoming clinical practice is the foundation for building longstanding relationships with lesbian patients. As reviewed in detail in the article by Cook et al in this issue, there are several steps that can be taken to create a welcoming and inclusive environment for LGBTQ patients.[8] In this instance, first impressions matter and it is important that all staff in the clinical practice are proficient in providing culturally competent care. The creation of a good relationship with the patient and her partner cannot depend exclusively on the midwife or obstetrician. Patients may not return to the practice if they have a negative experience with other team members, even if they have had a wonderful experience with the primary obstetrical care provider. The impression of an open and safe environment is reinforced by having lesbian families represented in the office décor and having lesbian-friendly pamphlets, reading material, and resources within the facility. The study by Seaver et al concluded that lesbian-specific reading material was vital for the patient's self-disclosure of sexual orientation.[9] In addition, practitioners need to assure the cultural competence of referral and complimentary services, especially prenatal education classes.

Heteronormative-based care arises from the assumption that “parents” and “couples” are a man and a woman. Lesbian couples report encountering heteronormative cues throughout the obstetrical process from antenatal care to postnatal care, in the form of verbal communication and prenatal education classes.[10] The history taking process is a critical point when rapport is either built or lost with lesbian patients and, therefore, presents an opportunity to break down heteronormative practices. A vital first step is having sexual orientation questions on intake forms and open sexual history conversations to reduce patient's fears of discrimination and signal to potential patients that the provider is queer friendly.[11] In the context of pregnancy, it is also important to acknowledge that our cultural constructs convey strong associations between pregnancy and femininity. Providers should be aware that these constructs pose challenges for some lesbians who contend with a conflict between being pregnant and a masculine self-concept.[12] A concrete means to overcome hetero- and gender-normative practices is to let lesbian couples self-identify their preferred terms (examples are in [Table 1]) and pronouns rather than imposing word choices upon them.

Table 1 Example of terms used by lesbian mothers

Pregnant patient	Nonpregnant partner
Mom	Another term for mom
Biologic/Nonbiologic mother[a]	Nonbiologic/Biologic mother[a]
Gestational mother	Nongestational mother
Birth/Birthing mother	Nonbirth/Nonbirthing mother
Co-mother	Co-mother
Carrying mother	Noncarrying mother
Parent	Parent

^a Term may be used if couple utilized nonpregnant partner's egg.

Preconception Counseling

An innovative study by Ruppel et al evaluated 1,764 posts in lesbian-oriented Facebook groups and found that 28% of the posts sought, or provided, medical advice and that the majority of these posts involved pregnancy concerns prior to conception.[13] Ideally, a women's health provider would be the first person consulted for medical information when she considers her options for pregnancy. To promote this, providers should be well prepared to help lesbian patients though the several decision points required to become parents. As outlined in [Table 2], couples must decide which partner will become pregnant, the mode by which to become pregnant, the origin of the egg, and the origin of the sperm. Individual and couple preferences, financial constraints, and legal protections influence each of these decision points. Women's health providers can facilitate safe and efficient pregnancy for lesbians by providing intrauterine insemination (IUI) with frozen sperm in their office. Best practices concerning provision of IUI with frozen sperm are outlined in a review article by Steele and Stratmann.[14] When needed, a referral should be made to a reproductive endocrinology and infertility (REI) doctor with a strong commitment to serving this community. Of note, the American Society of Reproductive Medicine (ASRM), like ACOG, has a policy statement calling for equal treatment of all requests for assisted reproduction without regard to marital/partner status or sexual orientation.[15]

Table 2 Pathways to pregnancy for lesbian couples

Mode of pregnancy
Home intrauterine insemination
Medical intrauterine insemination
Intercourse with opposite-sex partner
In-vitro fertilization
Egg origin
Patient
Partner
Donor
Sperm origin
Known donor
Anonymous donor[a]
Open donor[b]
Fresh semen
Frozen semen

Notes: The combination of mode of pregnancy, egg origin, and sperm origin can vary in each family and with each pregnancy.

^a Donor has not agreed to any contact with offspring.

^b Donor agrees to contact once child turns 18 years.

The couple (or single patient) have several decisions to make regarding the sperm donor ([Table 2]). First, they must decide between using a known and an anonymous donor. This choice is influenced by legal considerations, preferences as to the desired relationship with the donor, and, at times, concern about which option is best for their children. Importantly, psychological well-being has been demonstrated to be the same in children conceived by known or anonymous donors.[16] If using a known donor, the patient must decide between using fresh or frozen sperm. Patients considering using fresh semen and home insemination should be counseled regarding Zika virus precautions[17] and sexually transmitted disease (STD) testing for the donor, and informed that quarantined frozen semen has the lowest risk of infection. The Food and Drug Administration (FDA) recommends that known semen donors have infectious disease testing at the time of donation and every 6 months.[18] More information about the regulations regarding sperm donation can be found in the article in this issue by Getrajdman et al.[19] Financial considerations can influence the couple's approach to choosing a donor. Infectious disease testing, genetic testing, and preparation of a sample from a known donor cost between $3,200 and $4,000.[20] Anonymous cryopreserved sperm costs between $700 and $1,500 per vial (some REI practices require two vials/cycle) and, depending on state-level restrictions, the sperm may have to be obtained through a doctor's office. Since samples from a specific donor can be limited, families may also need to consider purchasing sperm in advance for future pregnancies, which would involve a storage fee of up to $500/year.

Couples choosing to use frozen sperm from an anonymous donor have several decisions to make about donor characteristics. If the patient has sickle cell trait or is a cystic fibrosis mutation carrier, this should be considered in the selection of a donor. Rh-status may also be considered and cytomegalovirus (CMV)-negative women should choose CMV-negative donors. Other donor characteristics that patients may consider include age, occupation, education, race, and physical features (height, weight, skin tone, and eye color). Among these, the donor's age and level of education were found to be the most important to couples in one study.[21] Some “open” donors allow for contact from the child after the child is 18 years old and online family-initiated donor sibling registries are facilitating connection between siblings from the same donor.[22] Donors' concerns regarding future contact from children conceived from donation is poorly studied; however, one study from the United Kingdom found that the majority of donors supported moves to increase release of information, but felt a strong need for control over their involvement.[23]

Co-mother Considerations

Little attention has been paid to the experiences and needs of the mother who does not carry the pregnancy. Women in this group often report a sense of exclusion from the obstetrical processes.[5] It is particularly difficult for these mothers when health care providers ask them who the real mother is, because this type of question implies that authentic motherhood can only come from carrying a child. In one of the few research studies focused on nonbirth mothers, Brennan and Sell reported that language strongly affects this group's transition to motherhood. Women in this study commented that terms like nonbirth and nonbiologic mother are difficult for them, as they reinforce awareness that they are not pregnant or biologically related to their children.[24] Forms that ask for the father's name and assumptions that they are the pregnant women's friend, sister, or mother exacerbate the sense of invisibility of the co-mother. Health care providers can relay that they affirm the parenthood of both partners by asking the couple what their preferred terms are, for example, “mommies” or “parents.”

Another unique challenge encountered by the nonpregnant mother is, occasionally, a feeling of jealousy of the birthing mother and the baby. A study from the University of California, Los Angeles, found that the likelihood of maternal jealousy was increased when both women desired to give birth to a child, when one or both partners experienced infertility, and when artificial insemination was the mode used to become pregnant. Feelings of jealously were mitigated, however, when the role of each partner in remunerative work and childcare were clearly defined.[25] Pregnancy by co–in vitro fertilization, as described in the study of Getrajdman et al in this issue, and bottle-feeding the infant so that both parents could be involved in feeding are also approaches that may decrease the risk of jealousy.[19]

Lesbian couples may also inquire about lactation induction for the nonpregnant partner. The literature on nonpuerperal lactation primarily consists of case reports in adoptive mothers[26] and an excellent review article by Bryant in 2006.[27] The most widely used approach for lactation induction is the Newman-Goldfarb protocol.[28] [29] The protocol is elaborate; it should be read in detail before it is prescribed to a patient[30] and collaboration with an International Board Certified Lactation Consultant can be considered. Briefly, 6 months before the expected due date, the prospective mother is started on continuous oral contraceptive pills (OCP) containing the equivalent of 1 mg norethindrone and 35 µg ethinyl estradiol plus domperidone 20 mg four times per day. Six weeks prior to the birth, the OCP is discontinued, the domperidone is continued, and the mother starts using a breast pump for 5 to 7 minutes every 3 hours. At this time, fenugreek seed and blessed thistle are added to the regimen. After 3 months of breast feeding, the domperidone is discontinued. No data could be found on the rate of lactation induction using this method, but it is reported that most people will need to supplement their milk supply. In one cohort study, subjects found induction of lactation in the nonbirth mother impractical given time constraints.[25] Another approach to feeding is to use a supplemental feeding device that delivers formula or partner's breastmilk through a small tube attached to the parent's chest.

By being aware of the challenges and strategies outlined earlier, the obstetrical care provider can build an inclusive environment that avoids marginalization of the co-mother and acknowledges the importance of both parents.

Considerations during Antenatal Care

The initial obstetrical visit is the ideal time for building rapport and obtaining a detailed medical history with consideration of lesbian-specific aspects of pregnancy. Asking appropriate questions to determine risk is not intrusive and is important for the provision of comprehensive obstetrical care. However, as in any patient encounter, it important that some questions are asked without the partner in the room and that patient's privacy is maintained. Providers can foster patient comfort by explaining why certain questions are asked. For example, determining how the lesbian couple became pregnant will influence the questions asked in a comprehensive history. If the pregnant mother utilized her partner's eggs to conceive, it would be reasonable to obtain a medical history of the partner, the pregnant patient, and the sperm donor.

Understanding health-related risk factors that disproportionally affect lesbians is crucial for providing comprehensive prenatal care. Studies have shown higher rates of tobacco smoking, obesity, alcohol use, advanced maternal age, nulliparity, and lack of knowledge of importance of preventative health screening in lesbian women when compared with heterosexual women.[9] [31] This places lesbians at increased risk for high blood pressure, breast cancer, and diabetes.[32] Finally, obstetrical care providers should screen all patients, including lesbians, for intimate partner violence, as 29.4% of lesbians report a history of severe physical violence by an intimate partner sometime during their lifetime.[33]

At the new obstetrical visit, the physical exam, screening laboratories, and ultrasounds are the same as those for heterosexual women. This includes STD screening, as female-to-female transmission is possible for all obstetrically relevant STDs, although some (such as bacterial vaginosis, HPV, and HSV-2) have a high prevalence among lesbians, while others (such as HIV and gonorrhea) are rare.[34] When obtaining a sexual history to assess STD risk, providers should not assume that lesbian patients are only sexually active with women. A study that included 6,935 self-identified lesbians found that 77.3% of respondents had one or more lifetime male sexual partners and 5.7% reported having had a male sexual partner in the past year.[35] Also, when obtaining an obstetrical history, it is important to note that an estimated 23.5% of lesbians have children from prior opposite-sex relationships.[2] In addition to sexual history, current sexual practices with female partners are important to determine because in certain high-risk pregnancies, some practices may pose a risk to the patient or fetus. Pregnancies complicated by placenta previa, increased risk of preterm labor, and maternal vaginal infections, for example, may preclude some sexual activities such as vaginal penetration. When counseling lesbian couples, statements such as “nothing inside the vagina” are useful, as opposed to “avoid sexual intercourse” as the latter may not be explicit enough and can be perceived as dismissive of lesbian sexuality. Lesbian sexual practices include, but are not limited to, insertive sex devices (toys), cunnilingus, digital/manual (vaginal and/or anal) stimulation, and genital-to-genital contact.[36] Examples of sexual and obstetrical history questions are included in [Table 3]. When asking these questions, an effort should be made to explain their medical context, conveying that obtaining a detailed sexual history is a standard part of obstetrical care. It may also be helpful to explain that these questions are asked because of the realization that assumptions should not be made about lesbian sexual practices.

Table 3 Obtaining a comprehensive sexual and obstetrical history

Sample sexual and obstetrical history questions
In your lifetime, have you had sex with men, women, or both?
In the past year, have you had sex with men, women, or both?
Have you ever been pregnant? If yes, tell me about your prior pregnancies.
Do you or your partner currently have sex with other people? If yes, with men, women, or both?
Do you have oral sex?
Do you have vaginal sex?
Do you have a need for postpartum contraception?

Intrapartum and Postpartum Care

Even if the obstetrical care provider and their outpatient clinical staff make significant efforts, the overall experience of the lesbian couple can still be largely negative if the labor and delivery and inpatient setting is not prepared to provide culturally competent care for your patients. One of the most effective means to institute these changes in your hospital is to advocate for your institution to participate in the Health Equality Index (HEI) through the Human Rights Campaign.[37] Similar to other national recognitions, like Leapfrog and baby friendly, a HEI designation is given to hospitals that meet national benchmarks for policies and practices that promote equity and inclusion for LGBTQ patients. The article by Cook et al in this issue provides discrete suggestions for ways to provide culturally competent care.[8] For example, the initial introduction between nursing staff and a couple is the opportune time to inquire about preferred terms, as every family is unique. This information can be conveyed to all other clinical teams, such as anesthesia, pediatrics, and the neonatal ICU, during handoffs, to avoid assumptions being made about the role of the co-mother (i.e., that she is the sister, friend, or mother of the pregnant patient).

Given the concerns of the co-mother discussed in the prior sections of this review, concerted efforts can be made to include her in the immediate events after the birth of the baby. In one study, nonbirth mothers reported that being the primary caregiver after birth helped facilitate attachment with the baby.[38] Additional measures can include having her engage in skin-to-skin contact immediately after the birth of the child. If the family is undertaking nonpuerperal lactation induction, then the co-mother should begin breastfeeding as soon as possible and breastfeeding will need to alternate between the two mothers. Baby identification bands should be given to both parents without asking the birth mother who should get the second band, as this would not be a question commonly asked to a married heterosexual couple.

During postpartum care, all standard postpartum recommendations are the same for lesbian patients as they are for heterosexual couples. Restrictions on sexual activity should be explicit in the context of lesbian sexual practices, as discussed in a previous section of this article. Also, depending on sexual practices, consideration may need to be given to postpartum contraceptive plans. As described by Stoffel et al in this issue[39] and in a recent article by Everett et al,[40] sexual minority women have unexpectedly high rates of unintended pregnancy. As in the general population, postpartum depression screening should be a central priority of postpartum care for lesbian patients, as this group has been reported to have higher Edinburgh Postnatal Depression Scale scores than heterosexual women.[41] Postpartum depression has been reported not only in the birth mother but also in the co-mother.[39] Factors found to be associated with postpartum depression in either mother include lack of support from families of origin, stress in negotiating parenting roles, and legal system barriers to establishing parental rights.[42]

Legal Considerations

Historically, lesbian couples contended with several legal barriers on their path to parenthood. Fortunately, in the United States, many of these barriers were mitigated with the introduction of the Affordable Care Act in 2010 and with the United States Supreme Court ruling (Obergefell v. Hodges in 2015) that gay marriage is a constitutional right that must be recognized by all states. However, not all lesbian couples decide to marry and even those who are married are pursuing additional legal protections for their family due to concerns about the volatility of the political climate in the United States. An exhaustive review of the legal intricacies of same-sex family law is beyond the scope of this article, but more information can be found in a review by Patterson from the University of Virginia.[43] Issues of particular relevance in the context of obstetrical care include the birth certificate and second parent adoption.[44] When a married woman gives birth, the department of vital records requires that her husband is listed on the child's birth certificate; unfortunately, several states have had policies that do not accommodate listing married or unmarried same-sex parents on birth certificates. However, in June 2017, in reference to Arkansas' refusal to place a lesbian nonbirth mother's name on the birth certificate of the couple's child, the U.S. Supreme Court ruled, in Pavan v. Smith, that states may not treat married same-sex couples differently from others in issuing birth certificates.[45] Of note, parents should be aware that being listed on the birth certificate does not guarantee the legal status of parent to the nonbiologic mother. To augment legal protections for the nonbiologic mother, some advocacy groups suggest that couples pursue second parent adoption if it is available in their state. Second parent adoption allows the nonbiologic mother to adopt her partner's biologic child without the birth mother terminating her own legal status as a parent. Given the complexity of these issues, the obstetrical care provider should be prepared to recommend local legal counsel with experience in same-sex law.

Conclusion

Fortunately, advocacy groups are working to ensure that health care settings are inclusionary of queer persons; however, an inclusive environment is most efficiently and authentically promoted through each health care provider expanding their personal networks and sharing information on an individual level. The obstetrical care provider is uniquely positioned in this endeavor, as becoming a parent is a momentous period in a person's life. In this role, an obstetrician or midwife can facilitate positive experiences for patients by honoring and respecting the pathway to parenthood in a holistic manner that includes the woman's female partner. From a health outcomes' perspective, lesbian-specific anticipatory guidance is crucial for preconception, pregnancy, and postpartum care. From a patient's perspective, provider comfort in caring for lesbians, knowledge of options for conception, and demonstrated concern for the couple's expectations are some of the attributes lesbian patients seek from a health care provider. Provider's confidence with this information will ideally lead to better experiences for patients, better outcomes for infants, and encourage lesbian women to have faith in the health care system instead of avoiding it.

Unfortunately, there is only limited scientific literature to inform our clinical care of lesbian patients. This is concerning because lesbian patients demonstrate distinct health needs and are disproportionally affected by health disparities. The inclusion of LGBTQ populations should be a priority in future research and more research specifically on lesbian pregnancy care is needed. Perhaps, the significant recent legal changes in the United States will improve health care outcomes for LGBTQ patients. Understanding of how these legal changes will affect the recommendations in this review article is yet to be determined.

Overall, as a profession, we have made and continue to make strides in the provision of culturally competent care for LGBTQ patients. Continuing to support and advocate for lesbian women through research, educating our professional peers, and by individually committing to being affirming health care providers will assure that we are facilitating the optimal pregnancy experience for all of our patients.

No conflict of interest has been declared by the author(s).

Acknowledgments

The authors would like to thank Gail Isenberg for her thoughtful comments and critical review of the manuscript.

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