Culturally Sensitive Obstetric Care for Pregnant Lesbian Women

Introduction and Case Description

I may have helped care for a number of pregnant lesbians without being aware of it, because I have certainly cared for unmarried mothers whose sexual orientation may not have been disclosed. What the literature has revealed is that many lesbians remain concerned about divulging their sexual orientation to healthcare professionals, including gynecologists, so that sexual orientation may remain unknown for many patients. However, I know that I have been involved in the care of at least one pregnant lesbian. The patient, whom I will call Leslie, was a 37-year-old woman who was pregnant for the second time. Her first pregnancy occurred when she was 15, and she placed that child for adoption.

Leslie was in a committed relationship with her "wife" — their state did not recognize same-sex marriage, so they were not legally married — a 34-year-old woman named Debbie. They were financially stable and appeared to have a functional relationship, though there were indications of excessive alcohol use by Leslie prior to conception. Because of her age, the pregnancy was considered high risk, and they had been involved with a fertility clinic. The baby was conceived through the use of an anonymous donor's sperm.

For a high-risk pregnancy, Leslie's prenatal care and treatment during birth and hospitalization were largely routine. There were some initial issues with Debbie being excluded from various parts of the process, but once staff understood that she was a family member, those issues were resolved quickly.

My perception of the care provided is almost certainly different from Debbie's perception. Debbie was somewhat confrontational with healthcare workers and seemed to interpret any perceived slight as discrimination based on her sexual orientation. For example, staff would not release information to her without Leslie's explicit approval — a protocol the office follows for all relationships, because pregnancy is a time when domestic violence issues frequently surface and the status of a relationship may change between visits. For the staff, this was a matter of patient privacy. Similarly, when Leslie needed an emergency cesarean section and Debbie was asked to leave the room during preparation, Debbie feared she would not be permitted back in for the delivery. Once it was explained that she would be readmitted after prep was complete, she calmed down immediately.

Some of the post-natal care raised interesting considerations, because routine post-natal visits include discussion of birth control — an issue that seemed inapplicable to this patient. However, Leslie herself raised the topic of low-dose hormonal birth control at her six-week post-natal checkup, citing concerns about heavy periods returning when she resumed menstruating. She also discussed her age and the desire to have more children, asking about optimal timing before attempting to conceive again.

Emotional Responses and Clinical Perceptions

I did not feel that Leslie's sexual orientation created any particular challenges in her treatment. However, I do believe that my perception of her care did not fully match the patient's or her partner's experience. For instance, unlike the vast majority of heterosexual patients of the same age in our care, Leslie had an unreliable history of gynecological care — she had not maintained yearly exams, though she had some history of gynecological checkups. Lesbians tend to be at lower risk of sexually transmitted diseases than the general population, but they are not in a zero-risk category, and many lesbians neglect their reproductive health because of a false sense of security.

I found my emotional response to Debbie to be considerably stronger than my response to Leslie, primarily because of Debbie's fear that, as a person with no legal relationship to the child, she might be excluded from parts of the prenatal process or even the birth itself. This did not appear to reflect any problems in their relationship; the two seemed committed and supportive of one another. Furthermore, there is a broader trend in obstetrics to communicate primarily with the patient rather than with the father, even when the mother has released information to him. Despite this context, Debbie remained convinced that information withheld without Leslie's permission would have been freely shared with a father. As a result, she was not always pleasant with office staff. While her attitude was no more aggressive than that of some fathers, I believe we could have taken greater steps to ensure she felt more included in the process.

When Debbie expressed concerns about having no legal relationship with the child, those concerns were extremely well-founded. It made me reflect on how difficult it must be to enter into a relationship with a child and parent with openness and love, knowing there was no legal recognition of that relationship. In some ways, I felt we were doing the child a disservice — not because the parents were lesbians, but because the child might be deprived of a relationship with one parent in the event of a separation.

Positive and Negative Aspects of the Experience

Every obstetric experience is unique, bringing its own challenges and opportunities. In this case, several things went well, and several were difficult. Most of the negative aspects were far more strongly correlated with maternal age than with any other factor. For example, Leslie's screening test results indicated a possible trisomy, requiring a difficult decision about amniocentesis, given that the procedure carries an increased risk of miscarriage. They ultimately decided against it. Leslie also experienced elevated blood pressure toward the end of her pregnancy — a potential health concern — but it was controlled and did not result in premature delivery or adverse consequences for maternal health. All of the negatives I identified were therefore unrelated to sexual orientation.

Interestingly, some of the more positive experiences were connected to the couple's sexual orientation, or perhaps to the fact that their orientation did not seem to matter much to those around them. Both Leslie and Debbie had the full support of both families. All four grandparents, several aunts and uncles, and young cousins awaited the birth of the newest family member while Leslie was in labor. One of Debbie's sisters accompanied Leslie to an ultrasound when Debbie was unavailable. The level of family support was, in fact, substantially higher than what one typically observes in heterosexual relationships in our practice.

I found this compelling, but I also recognized that my reaction may have been condescending. I had entered the situation with an assumption that lesbians would experience family rejection and lack support — a blanket assumption this experience clearly disproved. While family difficulties may be a reality for many members of the lesbian community, this case demonstrated that such assumptions cannot be applied universally.

I also believe that Leslie's sexual orientation was a contributing factor in her advanced age at first planned pregnancy. Because lesbians do not conceive incidentally as women in heterosexual relationships sometimes do, they must make more deliberate decisions about pregnancy and childbirth, which can delay conception. At the same time, as Leslie's teenage pregnancy illustrates, lesbian sexual orientation may in some cases lead to early and irresponsible sexual activity as young women attempt to prove heterosexuality to themselves or others.

References

Diamant, A. L., Wold, C., Spritzer, K., & Gelberg, L. (2000). Health behaviors, health status, and access to and use of health care: A population-based study of lesbian, bisexual, and heterosexual women. Arch. Fam. Med., 9(10), 1043–51.

McManus, A. J., Hunter, L. P., & Renn, H. (2006). Lesbian experiences and needs during childbirth: Guidance for health care providers. J. Obstet. Gynecol. Neonatal. Nurs., 35(1), 13–23.

McNair, R. P. (2003). Lesbian health inequalities: A cultural minority issue for health professionals. Med. J. Aust., 178(12), 643–5.

Moegelin, L., Nisson, B., & Helstrom, L. (2010). Reproductive health in lesbian and bisexual women in Sweden. Acta. Ostet. Gynecol. Scand., 89(2), 205–9.

Valanis, B. G., Bowen, D. J., Bassford, T., Whitlock, E., Charney, P., & Carter, R. A. (2000). Sexual orientation and health: Comparisons in the Women's Health Initiative sample. Arch. Fam. Med., 9(9), 842–53.