Individuals who identify as a sexual minority face higher risks of primary Cesarean birth compared with their completely heterosexual peers. Risks varied substantially across sexual-orientation subgroups, with the largest increase observed among a rarely examined group: people who identify as heterosexual but report prior same-sex experience. Disparities were especially pronounced when labor was induced.
This is according to a study – “Disparities in primary Cesarean birth by sexual orientation: a population-based analysis across three longitudinal cohorts” by Sarah McKetta, Kodiak R.S. Soledb, Payal Chakraborty, et al – that appeared in the Lancet Regional Health.
Here, the researchers analyzed pregnancy-level data from three large, long-running US cohort studies: Nurses’ Health Study 2 and 3 and the Growing Up Today Study. Together these cohorts span people born between 1947 and 1997 who were surveyed every one to three years.
“Very little national data captures both detailed sexual-orientation measures and birth outcomes,” said McKetta,. “By combining three rich national surveys, we were able to identify elevated risks among subgroups—particularly heterosexual participants with same-sex experience—who have been largely absent from perinatal research. We urge researchers to incorporate detailed orientation and gender-identity measures in future longitudinal studies to better understand these patterns.”
Sexual minority (SM) pregnancies represented 14% of all pregnancies in the sample, though less than 1% came from participants identifying as lesbian or gay. And the researchers found that, overall, SM participants had 7% higher odds of a primary Cesarean birth compared with completely heterosexual participants. SM pregnancies also occurred disproportionately among racially minoritized individuals.
The study also found higher rates of induced labor among sexual minority participants.
“This is notable,” McKetta said, “because the Cesarean disparity was greatest following induction — raising concerns about potential differences, including provider bias, in decision-making around interventions.”
Cesarean births account for more than 1.1 million surgeries each year in the US and represent 26% of low-risk births. Although often lifesaving, Cesareans are widely considered overused, contributing to higher healthcare costs and increased maternal morbidity.
“Future research should examine individual, interpersonal, and structural factors contributing to these disparities so we can design interventions that reduce them,” McKetta said. “Clinicians should also be mindful of unintentionally lowering the threshold for moving from induction to Cesarean among sexual minority patients, which may worsen existing inequities. Reducing unwarranted Cesareans in this population will improve health outcomes and support national goals to decrease primary Cesarean births.”
