Skip to main content
NCBI home page
JAMA Network logoLink to JAMA Network
. 2023 Aug 2;80(11):1142–1149. doi: 10.1001/jamapsychiatry.2023.2619

Perinatal Depression Screening Among Sexual Minority Women

Leiszle Lapping-Carr 1,✉, Ashley Dennard 1, Katherine L Wisner 1, S Darius Tandon 2
PMCID: PMC10398540  PMID: 37531104

Key Points

Question

Do sexual minority women giving birth at an academic medical center differ from heterosexual women in perinatal depression screening rates and scores?

Findings

In this cohort study of 18 234 women giving birth within 1 year, only 1.5% identified as having sexual minority status according to their medical records. After birth, sexual minority women were screened for depression at higher rates and had greater odds of screening positive for depression compared with heterosexual women.

Meaning

These findings suggest that, although sexual minority women are at high risk of postpartum depression, their sexual identities are largely undocumented in medical records, highlighting the need for strategies to measure sexual orientation that can reliably capture this information.

Abstract

Importance

A substantial number of births in the US are to sexual minority women (17% based on a nationally representative survey), yet there is little research on perinatal depression screening rates or symptom endorsement among sexual minority women (including women who identify as lesbian, bisexual, queer, pansexual, asexual, demisexual, and kinky as well as other-identified women who have sex with women). High rates of risk factors for perinatal depression (eg, intimate partner violence and history of mental illness) among sexual minority individuals magnify this gap in the literature.

Objective

To describe the prevalence of female-identified sexual minority people giving birth in an academic medical center and compare perinatal depression screening rates and scores among sexual minority women and heterosexual cisgender women.

Design, Setting, and Participants

This retrospective cohort study used deidentified medical record review of 18 243 female-identified individuals who gave birth at an academic medical center in Chicago, Illinois, between January 1 and December 31, 2019. Data were analyzed from April 5, 2021, to August 1, 2022.

Main Outcomes and Measures

Proportion of women identified as having sexual minority status in the medical record, rates of standard care administration of the 9-item Patient Health Questionnaire between sexual minority women and heterosexual women, and depression screening scores and rates of positive depression screening results for sexual minority and heterosexual women.

Results

Among 18 243 women (mean [SD] age, 33.8 [5.1] years; 10 453 [57.3%] of non-Hispanic White race and ethnicity), only 280 (1.5%; 95% CI, 1.3%-1.7%) were identified as having sexual minority status in the medical record. Significantly more sexual minority women vs heterosexual women attended at least 1 prenatal care visit (56 [20.0%] vs 2459 [13.7%]; P = .002) and at least 1 postpartum care visit (52 [18.6%] vs 2304 [12.8%]; P = .004). Sexual minority women were more likely to be screened for depression during postpartum care (odds ratio, 1.77; 95% CI, 1.22-2.52; P = .002) and more likely to screen positive for depression during the postpartum period (odds ratio, 2.38; 95% CI, 0.99-5.02; P = .03) than heterosexual women.

Conclusions and Relevance

In this cohort study, sexual minority women identified in the medical record were highly engaged in obstetric care yet at high risk of postpartum depression. In addition, their sexual orientation was largely undocumented in medical records. These results highlight the need for investigations that include strategies for measuring sexual orientation because medical record review is unlikely to reliably capture these sexual identities during the perinatal period.

This cohort study assesses the prevalence of sexual minority women giving birth in an academic medical center within 1 year and compares perinatal depression screening rates and scores among sexual minority vs heterosexual women.

Introduction

Perinatal depression is defined in the DSM-V as a major depressive episode during pregnancy and/or in the 4 weeks after childbirth.1 Perinatal depression is the most common complication of the perinatal period, with a prevalence of approximately 17%2 and a societal cost of more than $14.2 billion annually in the US.3 Pregnant people with depression are more than 1.5 times more likely to give birth preterm than those without depression.4 Perinatal depression has adverse effects on offspring’s cognitive, behavioral, psychomotor, and socioemotional development.5 Minority stress, the stress caused by the discrimination and stigma experienced by minority individuals, such as those belonging to racial and ethnic minority groups,6 exacerbates these adverse effects.7,8

Little is known about the prevalence or sequelae of perinatal depression among sexual minority cisgender women, defined as people assigned female at birth and self-identified as women (cisgender) who have sexual or romantic relationships with other women and/or do not identify as exclusively heterosexual. Sexual minority women include women who identify as lesbian, bisexual, queer, pansexual, asexual, demisexual, and kinky as well as other-identified women who have sex with women.9,10,11 Approximately 1 in 6 US births occur among sexual minority women,12 representing more than 635 000 births annually.13 A recent systematic review14 of 26 studies involving 1199 participants described features of perinatal mental health among sexual and gender minority individuals. The prevalence of clinically meaningful perinatal depression ranged from 8% to 24%. Sexual minority women endorsed more severe depressive symptoms and higher prevalence of clinical depression during the postpartum period than heterosexual women, although no differences were found during pregnancy.14

Risk factors for perinatal depression among sexual minority women are unknown; however, sexual minority women generally report higher rates of risk factors observed in heterosexual women,7,15 including depression, stressful life events, limited social support, and intimate partner violence.16,17 Bisexual women consistently endorse the highest rates of mental illness,18 sexual assault,19 and stigmatization.20 Minority stress, including discrimination in health care based on sexual orientation, is an additional risk factor for sexual minority women.21,22,23,24 Protective factors for lesbian coparents include high levels of reciprocal emotional and functional support25 and preparation for parenthood.22 The extent to which these protective factors extend to other-identified sexual minority women is unclear.

Clinical guidelines recommend universal perinatal depression screening at obstetric and pediatric well-infant visits.26,27 The 9-item Patient Health Questionnaire (PHQ-9)28 is commonly used to screen for perinatal depression and has established score categories that enable identification of levels that warrant treatment.27 However, universal screening remains an unfulfilled goal,26 as revealed in a systematic review29 of studies about perinatal depression diagnostic and treatment rates. Among people meeting criteria for prenatal or postpartum depression, only 50% and 31%, respectively, were identified in the clinical setting, only 14% and 16% received treatment, and only 8.6% and 6.3% received adequate treatment.29 A study30 examining online posts from a community of lesbian mothers extracted qualitative themes describing exclusion from mental health care, such as no screening for mental illness by perinatal care clinicians.

There are major gaps in the perinatal depression literature with respect to sexual minority women. Only 1 study12 has provided an estimate of the number of sexual minority women giving birth each year, with no studies, to our knowledge, examining screening rates for perinatal depression among sexual minority women. In a meta-analysis,14 included studies that estimated the prevalence of perinatal depression among sexual minority women had small sample sizes with little racial, ethnic, or socioeconomic diversity. Given that approximately one-third of sexual minority women self-identify as having racial and ethnic minority status,31 the studies in the meta-analysis14 are not representative.

The current study addressed these limitations by describing the proportion of sexual minority women in a large and ethnically diverse sample through a medical record review of all people giving birth in a single year at an urban hospital that serves a socioeconomically diverse population (approximately 38% of patients are uninsured or publicly insured). Potential disparities in perinatal depression screening rates and mean scores were examined. The primary aims of this study were to (1) identify the proportion of sexual minority women giving birth at an academic medical center in a calendar year, (2) assess the percentage of sexual minority and heterosexual women screened at least once for depression during prenatal care and at least once during the first 3 months of postpartum care, and (3) compare depression screening scores between sexual minority and heterosexual women in the prenatal and postpartum periods.

Methods

This retrospective cohort study used medical records from all individuals giving birth between January 1 and December 31, 2019. Data were analyzed from April 5, 2021, to August 1, 2022. An institutional service for data integration and transfer was used to obtain the variables of interest from medical records. No identifiable information was included, and all data were collected as part of standard clinical care. This study was deemed exempt from institutional review board review based on the Northwestern University policy that fully deidentified data obtained from medical records are not considered human research under US Department of Health and Human Services and US Food and Drug Administration regulations.32 Informed consent was waived due to the use of retrospective deidentified data. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cohort studies.33

Participants

Participants included 18 243 female-identified individuals who gave birth at a university-affiliated medical center in Chicago, Illinois, in 2019. Data included information available through deidentified medical record review. Because this was an exploratory study using retrospective data extraction, there were no formal sample size calculations.

One participant had a male gender marker in his record; all other participants had a female gender marker, indicating they were cisgender women. We excluded the male participant from the results given the inability to make meaningful comparisons with a single participant. Participants were predominantly heterosexual, with 280 identifying as sexual minority women (21 identified as lesbian, 35 as bisexual, and 224 as not specified).

Procedure

Age, race, ethnicity, gender, and relationship status were obtained from the demographics section of each patient’s medical record. Conception method and birth condition were obtained from the obstetric delivery note. Sexual minority status was identified by (1) the sexual orientation and gender identity field (n = 56); (2) a text-based search of all progress notes for identification of the patient as lesbian, bisexual, same-sex attracted, or queer (n = 134); or (3) identification of a wife in the emergency contact field (n = 90). Per hospital protocol, patients giving birth were screened for depressive symptoms using the PHQ-9 (score range, 0-27, with higher scores indicating greater severity of depression symptoms)29; scores were documented in the medical record. For this study, we used PHQ-9 screenings completed during pregnancy and up to 3 months post partum. If the participant had multiple screenings, the mean PHQ-9 score was used for analyses.

Measures

Demographic Data and Sexual Minority Status

Demographic data included age, race and ethnicity, relationship status, method of conception (in vitro fertilization [IVF] vs no IVF), and birth condition (fetal or neonatal death vs live birth). There is no standard procedure for measurement of sexual identity, and medical records default to listing patients as heterosexual. Sexual minority status was measured with a binary yes or no indicator. We collected descriptive data on identity as lesbian or bisexual; however, these subgroups were not examined in analyses.

Depression

The PHQ-928 is a self-report questionnaire (score range, 0-27, with higher scores indicating greater severity of depression symptoms) that is used extensively in integrated care settings, including obstetric clinics. In this study, a positive result for depression was defined as a total score greater than 9 on the PHQ-9. A recent meta-analysis27 examining the use of the PHQ-9 among the perinatal population found a pooled sensitivity of 0.84, specificity of 0.81, and area under the receiver operating characteristic curve of 0.89, indicating good reliability and validity. The PHQ-9 has had mixed results in validation studies among sexual minority women34,35,36 and has not been validated among sexual minority women during the perinatal period. We were unable to report psychometric data for this sample because we did not have access to individual item responses.

Statistical Analysis

Analyses were conducted using the stats package in R software, version 4.1.1 (R Foundation for Statistical Computing). The threshold for statistical significance was 2-tailed P = .05. We used χ2 analyses to identify differences in demographic characteristics between sexual minority and heterosexual women. For aim 1 (proportion of sexual minority women) analyses, sample proportions and corresponding 95% CIs were calculated. Binary analyses for aim 2 (screening rates) and aim 3 (positive depression screening results) consisted of logistic regression and χ2 analyses. Odds ratios (ORs) and 95% CIs were calculated. Analysis of continuous depressive symptom score data in aim 3 included linear regression models to examine the extent to which sexual minority status was associated with PHQ-9 scores. We examined the residual diagnostic data to assess whether assumptions of linear regression were being violated or the residuals were significantly skewed. We used a square root transformation to address the multiple 0 values from participants who endorsed no depressive symptoms.37 The transformation resolved the skew and maintained adherence with the other assumptions of linear regression. Square root–transformed values were reported in this article.

In both logistic and linear regression analyses, we included age, method of conception, race and ethnicity, and relationship status as covariates. Sexual minority and heterosexual women have been reported to differ on some of these variables,12,14 which are associated with depressive symptoms.2,7 We included them as covariates to determine whether sexual minority status was associated with depression beyond what was explained by these variables. We also included the number of prenatal or postpartum visits as a covariate in the analyses examining receipt of a prenatal or postpartum PHQ-9 screening, respectively. Race and ethnicity data were collected and analyzed because substantial pregnancy-related8 and depression-related38,39 health disparities between different racial and ethnic groups have been reported, and without analysis of these variables, we would have been unable to identify a potentially significant association between sexual minority status and perinatal depression. Missing covariate data were handled using restricted maximum likelihood, which includes all available data and produces relatively unbiased parameter estimates compared with maximum likelihood and listwise or pairwise deletion.40

Results

Demographic Characteristics and Differences

Among 18 243 women, the mean (SD) age was 33.8 (5.1) years; most women were of non-Hispanic White race and ethnicity (10 453 [57.3%]) (Table 1). We found significant differences in sexual minority women (n = 280) vs heterosexual women (n = 17 963) with regard to relationship status, with sexual minority women reporting lower rates of marriage (189 [67.5%] vs 13 672 [76.1%]; P < .001), higher rates of divorce or separation (8 [2.9%] vs 99 [0.6%]; P < .001), and higher rates of having a significant other (14 [5.0%] vs 347 [1.9%]; P < .001). Sexual minority women also had higher rates of IVF conception (10 [3.6%] vs 154 [0.9%]; P < .001) than heterosexual women.

Table 1. Participant Characteristics.

Characteristic Participants, No. (%)
Heterosexual women (n = 17 963) Sexual minority women (n = 280) P value
Age, mean (SD), y 33.8 (5.1) 34.4 (5.6) .07
Cisgender 17 963 (100) 280 (100) NAa
Race and ethnicity
American Indian or Alaska Native 47 (0.3) 0 .01
Asian 1394 (7.8) 14 (5.0)
Black or African American 1519 (8.5) 30 (10.7)
Hispanic or Latina 3312 (18.4) 35 (12.5)
Native Hawaiian or Pacific Islander 28 (0.2) 0
White 10 278 (57.2) 175 (62.5)
Other 579 (3.2) 15 (5.4)
No information 806 (4.5) 11 (3.9)
Relationship status
Married 13 672 (76.1) 189 (67.5) <.001
In a relationship with a significant other 347 (1.9) 14 (5.0)
Single 3642 (20.3) 69 (24.6)
Divorced or separated 99 (0.6) 8 (2.9)
Widowed or other 33 (0.2) 0
No information 170 (0.9) 0
Birth condition
Fetal or neonatal death 150 (0.7) 4 (1.4) .34
Live birth 16 140 (89.9) 255 (91.1)
No information 1673 (9.3) 21 (7.5)
IVF conception 154 (0.9) 10 (3.6) <.001
Open in a new tab

Abbreviations: IVF, in vitro fertilization; NA, not applicable.

a

No P value because gender identity comparison was not conducted.

Proportion of Sexual Minority Women

Of the 18 243 women who gave birth in the hospital, 280 were identified as having sexual minority status in their medical records. This yielded a proportion of 1.5% (95% CI, 1.3%-1.7%) of sexual minority women giving birth in a single year. Given the small proportion of sexual minority women in the sample, the subsequent screening and depression symptom results should be considered as preliminary and in need of further investigation.

Proportion of Women Screened With PHQ-9

The percentages of women receiving PHQ-9 screening during prenatal and postpartum visits, stratified by sexual minority status, are shown in Table 2. Screening rates by racial and ethnic group are available in eTables 1 and 2 in Supplement 1. Significantly more sexual minority women than heterosexual women attended at least 1 prenatal care visit (56 [20.0%] vs 2459 [13.7%]; P = .002) and at least 1 postpartum care visit (52 [18.6%] vs 2304 [12.8%]; P = .004).

Table 2. Characteristics of Prenatal and Postpartum Visits, PHQ-9 Screenings, and PHQ-9 Scores by Sexual Orientation.

Characteristic Participants, No./total No. (%)
Heterosexual women (n = 17 963) Sexual minority women (n = 280) P value
Prenatal care
Attended ≥1 care visits 2459/17 963 (13.7) 56/280 (20.0) .002
Received ≥1 PHQ-9 screenings 3572/17 963 (19.9) 78/280 (27.9) .06
PHQ-9 score, mean (SD)a 3.28 (2.95) 3.72 (3.80) .45
Positive PHQ-9 resultb,c 275/3572 (7.7) 5/78 (6.4) .40
Postpartum care
Attended ≥1 care visits 2304/17 963 (12.8) 52/280 (18.6) .004
Received ≥1 PHQ-9 screenings 2792/17 963 (15.5) 69/280 (24.6) .002
PHQ-9 score, mean (SD)a 2.77 (3.34) 3.95 (5.09) .08
Positive PHQ-9 resultb,c 272/2792 (9.7) 8/69 (11.6) .03
Open in a new tab

Abbreviation: PHQ-9, 9-item Patient Health Questionnaire.

a

Score range, 0-27, with higher scores indicating greater severity of depression symptoms.

b

A positive result for depression was defined as a total score greater than 9 on the PHQ-9.

c

Percentage among patients who received at least 1 PHQ-9 screening.

Among 18 243 participants, 3650 (20.0%) received a prenatal depression screening, and 2861 (15.7%) received a postpartum depression screening. No significant difference between the proportion of sexual minority and heterosexual women who received a PHQ-9 screening during the prenatal period was observed (OR, 1.47; 95% CI, 0.97-2.16; P = .06) (Figure). However, sexual minority women were more likely than heterosexual women to receive a PHQ-9 screening during the postpartum period (OR, 1.77; 95% CI, 1.22-2.52; P = .002).

Figure. Odds of Receiving Depression Screening and Positive Screening Result for Depression Among Sexual Minority Women.

Figure.

Open in a new tab

A positive result for depression was defined as a total score greater than 9 on the 9-item Patient Health Questionnaire (PHQ-9; score range, 0-27, with higher scores indicating greater severity of depression symptoms). OR indicates odds ratio.

Depression Screening Scores

No significant association between sexual minority status and prenatal PHQ-9 scores (B [SE], 0.07 [0.10]; 95% CI, −0.12 to 0.26; P = .45) or postpartum PHQ-9 scores (B [SE], 0.21 [0.12]; 95% CI, −0.02 to 0.45; P = .07) was found. We also examined differences in the proportion of women screening positive for depression on the PHQ-9 (score >9). This assessment of differences provided important information on the clinical presentation of depression and reduced the implications of skew in mean scores for the significance of results. A total of 280 of 3650 women (7.7%) who received prenatal screening and 280 of 2861 (9.8%) women who received postpartum screening were included in the analysis. Among those who received at least 1 PHQ-9 screening in the prenatal period, 5 of 78 sexual minority women (6.4%) and 275 of 3572 heterosexual women (7.7%) had positive results for depression. Among those with at least 1 PHQ-9 screening in the postpartum period, 8 of 69 sexual minority women (11.6%) and 272 of 2792 heterosexual women (9.7%) had positive results for depression. Using logistic regression analysis, we found that sexual minority women were more likely than heterosexual women to screen positive for depression during the postpartum period (OR, 2.38; 95% CI, 0.99-5.02; P = .03), although this difference did not reach statistical significance (Figure). No significant difference in the proportion of positive depression results during the prenatal period (OR, 1.50; 95% CI, 0.51-3.55; P = .40) was found.

Discussion

For aim 1 of this cohort study, we calculated the proportion of sexual minority women giving birth in a medical center during 2019. Only 1.5% of birthing people identified as sexual minority women according to medical records. This proportion was substantially lower than the 17% reported by Everett et al,12 which was obtained through self-reported sexual experiences and orientation. This difference likely reflects a lack of recognition or documentation rather than an accurate representation of the proportion of sexual minority women giving birth. The study by Everett et al12 included a nationally representative sample of women and measured sexual orientation and same-sex sexual behavior, inclusive of women who have sex with women regardless of their sexual identity. Using sexual identity and behavior to measure sexual minority status is standard practice in sexual minority health research.11

Many factors likely played a role in the small proportion of sexual minority women in this study. Many sexual minority women choose not to disclose their sexual orientation to health care workers, citing fears of discrimination or the belief that their sexual orientation is irrelevant to their care.41 It is also possible that clinicians did not document sexual orientation in the medical record if disclosed, either because of patient preference or unclear documentation protocols. Furthermore, many sexual minority women receive prenatal care outside of hospitals from midwives or private clinics specializing in prenatal care for those with sexual minority status.42

Therefore, hospital medical records are unlikely to provide a representative estimate of the percentage of sexual minority women giving birth in the US. Few options for large-scale examination of the perinatal mental health of sexual minority women are available. No national data sets adequately measure sexual minority status and perinatal mental health. Perinatal mental health research rarely measures or describes the sexual orientation of participants.43 Accepted measures include multiple dimensions of sexual orientation and gender identity and a range of response options, including unsure or choose not to disclose.44 To protect against potential discrimination in health care, research protocols should include protections to ensure identity disclosures are confidential.

For aim 2, we compared depression screening rates among sexual minority and heterosexual women. Although sexual minority women were more likely to receive a PHQ-9 screening during the postpartum period than their heterosexual counterparts, no difference in prenatal screening rates was observed. Pregnant people from racial and ethnic minority groups are less likely to receive depression screenings and treatment referrals in medical settings38,39; however, sexual minority status is largely undocumented and may not be subject to the same bias as racial and ethnic minority status. It is also possible that sexual minority women in our study were particularly well resourced, highly educated, and engaged in their care, which is supported by their higher engagement with perinatal care.45 Care engagement may be an important protective factor to consider in intervention development and implementation. We were not able to examine factors associated with socioeconomic status or educational level as part of this study.

For aim 3, we examined the association between depression screening scores and sexual orientation, using continuous (mean or total score) and binary (positive screening result for depression) analyses. Sexual minority women had higher odds of screening positive for depression during the postpartum period compared with heterosexual women; however, all other comparisons were nonsignificant. This finding was consistent with the existing literature.14,16,46,47 A recent systematic review14 noted that minority stress may become more problematic for sexual minority women during the vulnerable postpartum period. For example, sexual minority women may experience social stigma related to being perceived as inadequate parents, heteronormativity in perinatal care (eg, intake forms asking for information about the child’s father), and lack of familial social support due to nonacceptance of sexual orientation.

It is notable that sexual minority women in the sample were highly engaged in care and similar to heterosexual women in depression screening rates and symptom scores. We did not have access to information about the specific stressors or protective factors experienced by the people in this study. Community resiliency is 1 factor that may have played a role in these positive screening results. Higher community engagement and support has been found to improve perinatal mental health.48

Limitations

This study has several limitations. First, the study relied on medical record review. Women who did not disclose a sexual minority identity or did not have their identity documented in their medical records were incorrectly included in the group of heterosexual women. In addition, only 1 birthing individual in the sample had a nonfemale gender marker despite the fact that many gender-diverse individuals experience pregnancy and mental illness.49,50 While medical record review can offer insights about perinatal depression among those correctly identified as sexual minority women, reductions in discrimination and stigma in the health care system will be necessary for sexual minority women to willingly disclose and have their identities documented. Staff and clinician training on queer-affirming practices and more visibly inclusive clinic spaces are initial steps toward providing safe environments for sexual minority women.14 Another option for improving reliable reporting of sexual identities is through explicit separation of research data from clinical records to protect against identity disclosure.

Second, the overall rate of screening was low although consistent with a recent report51 on screening rates across the US. Only 20.0% of sexual minority and heterosexual women in the current study received a prenatal depression screening, and only 15.7% received a postpartum depression screening. Furthermore, the endorsement of clinical depression among the entire study sample (7.7% prenatally and 9.8% postnatally) was at the low end of the range reported in the literature (6.5%-17.0%).7 Low rates of screening and symptom endorsement may have limited the variability in the data and exaggerated or minimized the associations reported. Because the results are consistent with previous research,14 the overall conclusions are likely accurate.

Third, we were unable to examine many social determinants of health using medical record review. Low socioeconomic status, experiences of discrimination, and poor physical health all have implications for the risk of depression52,53 and warrant investigation as moderating factors. A related area for future research is examination of the association between multiple marginalized identities and perinatal mental health using an intersectional framework.54,55

Fourth, our data came from a single medical center serving a midwestern urban population. The extent to which our results generalize to other medical systems or other locations is unknown. This study was a first attempt at characterizing perinatal depression screening practices among sexual minority women. Evaluating different hospital protocols will be important in developing best practice consensus guidelines.

Conclusions

To our knowledge, this cohort study was the first to examine perinatal depression screening and symptom endorsement among sexual minority women in a major medical center in the US. The findings provide evidence that sexual minority women are at higher risk of postpartum depression compared with heterosexual women. Results also highlight the need for investigations that include strategies for measuring sexual orientation because reliance on medical record review has substantial limitations with regard to the research questions and the validity of the data.

Supplement 1.

eTable 1. Descriptive Statistics of Prenatal Visits, PHQ-9 Screenings, and PHQ-9 Scores, Split by Sexual Orientation and Race and Ethnicity

eTable 2. Descriptive Statistics of Postpartum Visits, PHQ-9 Screenings, and PHQ-9 Scores, Split by Sexual Orientation and Race and Ethnicity

Click here for additional data file. (95.7KB, pdf)
Supplement 2.

Data Sharing Statement

Click here for additional data file. (13.3KB, pdf)

References

  • 1.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013. [Google Scholar]
  • 2.Underwood L, Waldie K, D’Souza S, Peterson ER, Morton S. A review of longitudinal studies on antenatal and postnatal depression. Arch Womens Ment Health. 2016;19(5):711-720. doi: 10.1007/s00737-016-0629-1 [DOI] [PubMed] [Google Scholar]
  • 3.Luca DL, Garlow N, Staatz C, et al. Societal costs of untreated perinatal mood and anxiety disorders in the United States. Mathmatica Policy Research. April 29, 2019. Accessed June 29, 2023. https://www.mathematica.org/publications/societal-costs-of-untreated-perinatal-mood-and-anxiety-disorders-in-the-united-states [Google Scholar]
  • 4.Smith MV, Shao L, Howell H, Lin H, Yonkers KA. Perinatal depression and birth outcomes in a Healthy Start project. Matern Child Health J. 2011;15(3):401-409. doi: 10.1007/s10995-010-0595-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Kingston D, Tough S, Whitfield H. Prenatal and postpartum maternal psychological distress and infant development: a systematic review. Child Psychiatry Hum Dev. 2012;43(5):683-714. doi: 10.1007/s10578-012-0291-4 [DOI] [PubMed] [Google Scholar]
  • 6.Meyer IH, Frost DM. Minority stress and the health of sexual minorities. In: Patterson CJ, D’Augelli AR, eds. Handbook of Psychology and Sexual Orientation. Oxford University Press; 2012. doi: 10.1093/acprof:oso/9780199765218.003.0018 [DOI] [Google Scholar]
  • 7.Dagher RK, Bruckheim HE, Colpe LJ, Edwards E, White DB. Perinatal depression: challenges and opportunities. J Womens Health (Larchmt). 2021;30(2):154-159. doi: 10.1089/jwh.2020.8862 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Collier ARY, Molina RL. Maternal mortality in the United States: updates on trends, causes, and solutions. Neoreviews. 2019;20(10):e561-e574. doi: 10.1542/neo.20-10-e561 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Edwards OW, Lev E, Obedin-Maliver J, et al. Our pride, our joy: an intersectional constructivist grounded theory analysis of resources that promote resilience in SGM communities. PLoS One. 2023;18(2):e0280787. doi: 10.1371/journal.pone.0280787 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Sprott RA, Benoit Hadcock B. Bisexuality, pansexuality, queer identity, and kink identity. Sex Relation Ther. 2018;33(1-2):214-232. doi: 10.1080/14681994.2017.1347616 [DOI] [Google Scholar]
  • 11.Young RM, Meyer IH. The trouble with “MSM” and “WSW”: erasure of the sexual-minority person in public health discourse. Am J Public Health. 2005;95(7):1144-1149. doi: 10.2105/AJPH.2004.046714 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Everett BG, Kominiarek MA, Mollborn S, Adkins DE, Hughes TL. Sexual orientation disparities in pregnancy and infant outcomes. Matern Child Health J. 2019;23(1):72-81. doi: 10.1007/s10995-018-2595-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Martin JA, Hamilton BE, Osterman MJK, Driscoll AK. Births: final data for 2019. Natl Vital Stat Rep. 2021;70(2):1-51. [PubMed] [Google Scholar]
  • 14.Kirubarajan A, Barker LC, Leung S, et al. LGBTQ2S+ childbearing individuals and perinatal mental health: a systematic review. BJOG. 2022;129(10):1630-1643. doi: 10.1111/1471-0528.17103 [DOI] [PubMed] [Google Scholar]
  • 15.Cankorur VS, Abas M, Berksun O, Stewart R. Social support and the incidence and persistence of depression between antenatal and postnatal examinations in Turkey: a cohort study. BMJ Open. 2015;5(4):e006456. doi: 10.1136/bmjopen-2014-006456 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Ross LE, Steele L, Goldfinger C, Strike C. Perinatal depressive symptomatology among lesbian and bisexual women. Arch Womens Ment Health. 2007;10(2):53-59. doi: 10.1007/s00737-007-0168-x [DOI] [PubMed] [Google Scholar]
  • 17.Matthews AK, Hughes TL, Johnson T, Razzano LA, Cassidy R. Prediction of depressive distress in a community sample of women: the role of sexual orientation. Am J Public Health. 2002;92(7):1131-1139. doi: 10.2105/AJPH.92.7.1131 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Feinstein BA, Dyar C. Bisexuality, minority stress, and health. Curr Sex Health Rep. 2017;9(1):42-49. doi: 10.1007/s11930-017-0096-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Chen J, Walters ML, Gilbert LK, Patel N. Sexual violence, stalking, and intimate partner violence by sexual orientation, United States. Psychol Violence. 2020;10(1):110-119. doi: 10.1037/vio0000252 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Bostwick W. Assessing bisexual stigma and mental health status: a brief report. J Bisex. 2012;12(2):214-222. doi: 10.1080/15299716.2012.674860 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Trettin S, Moses-Kolko EL, Wisner KL. Lesbian perinatal depression and the heterosexism that affects knowledge about this minority population. Arch Womens Ment Health. 2006;9(2):67-73. doi: 10.1007/s00737-005-0106-8 [DOI] [PubMed] [Google Scholar]
  • 22.Ross LE. Perinatal mental health in lesbian mothers: a review of potential risk and protective factors. Women Health. 2005;41(3):113-128. doi: 10.1300/J013v41n03_07 [DOI] [PubMed] [Google Scholar]
  • 23.Li CC, Matthews AK, Aranda F, Patel C, Patel M. Predictors and consequences of negative patient-provider interactions among a sample of African American sexual minority women. LGBT Health. 2015;2(2):140-146. doi: 10.1089/lgbt.2014.0127 [DOI] [PubMed] [Google Scholar]
  • 24.Argyriou A, Goldsmith KA, Rimes KA. Mediators of the disparities in depression between sexual minority and heterosexual individuals: a systematic review. Arch Sex Behav. 2021;50(3):925-959. doi: 10.1007/s10508-020-01862-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Ross LE, Steele L, Sapiro B. Perceptions of predisposing and protective factors for perinatal depression in same-sex parents. J Midwifery Womens Health. 2005;50(6):e65-e70. doi: 10.1016/j.jmwh.2005.08.002 [DOI] [PubMed] [Google Scholar]
  • 26.Goodman JH. Perinatal depression and infant mental health. Arch Psychiatr Nurs. 2019;33(3):217-224. doi: 10.1016/j.apnu.2019.01.010 [DOI] [PubMed] [Google Scholar]
  • 27.Wang L, Kroenke K, Stump TE, Monahan PO. Screening for perinatal depression with the Patient Health Questionnaire depression scale (PHQ-9): a systematic review and meta-analysis. Gen Hosp Psychiatry. 2021;68:74-82. doi: 10.1016/j.genhosppsych.2020.12.007 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. doi: 10.1046/j.1525-1497.2001.016009606.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Cox EQ, Sowa NA, Meltzer-Brody SE, Gaynes BN. The perinatal depression treatment cascade: baby steps toward improving outcomes. J Clin Psychiatry. 2016;77(9):1189-1200. doi: 10.4088/JCP.15r10174 [DOI] [PubMed] [Google Scholar]
  • 30.Alang SM, Fomotar M. Postpartum depression in an online community of lesbian mothers: implications for clinical practice. J Gay Lesbian Ment Health. 2015;19(1):21-39. doi: 10.1080/19359705.2014.910853 27076865 [DOI] [Google Scholar]
  • 31.Pew Research Center. A survey of LGBT Americans: attitudes, experiences and values in changing times. Pew Research Center. June 13, 2013. Accessed June 29, 2023. https://www.pewresearch.org/social-trends/2013/06/13/a-survey-of-lgbt-americans [Google Scholar]
  • 32.Protection of Human Subjects, 45 CFR §46 (2018). Accessed June 29, 2023. https://www.ecfr.gov/on/2018-07-19/title-45/subtitle-A/subchapter-A/part-46
  • 33.von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative . The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med. 2007;147(8):573-577. doi: 10.7326/0003-4819-147-8-200710160-00010 [DOI] [PubMed] [Google Scholar]
  • 34.Borgogna NC, Brenner RE, McDermott RC. Sexuality and gender invariance of the PHQ-9 and GAD-7: implications for 16 identity groups. J Affect Disord. 2021;278:122-130. doi: 10.1016/j.jad.2020.09.069 [DOI] [PubMed] [Google Scholar]
  • 35.Nguyen TQ, Bandeen-Roche K, Bass JK, German D, Nguyen NTT, Knowlton AR. A tool for sexual minority mental health research: the Patient Health Questionnaire (PHQ-9) as a depressive symptom severity measure for sexual minority women in Viet Nam. J Gay Lesbian Ment Health. 2016;20(2):173-191. doi: 10.1080/19359705.2015.1080204 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Aníbal González-Rivera J. Validation and dimensionality of Patient Health Questionnaire for depression (PHQ-8 and PHQ-9) in Hispanic LGBT+ community. Int J Recent Sci Res. 2019;10(12):36670-36676. [Google Scholar]
  • 37.Manikandan S. Data transformation. J Pharmacol Pharmacother. 2010;1(2):126-127. doi: 10.4103/0976-500X.72373 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Hahm HC, Le Cook B, Ault-Brutus A, Alegría M. Intersection of race-ethnicity and gender in depression care: screening, access, and minimally adequate treatment. Psychiatr Serv. 2015;66(3):258-264. doi: 10.1176/appi.ps.201400116 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Shao Z, Richie WD, Bailey RK. Racial and ethnic disparity in major depressive disorder. J Racial Ethn Health Disparities. 2016;3(4):692-705. doi: 10.1007/s40615-015-0188-6 [DOI] [PubMed] [Google Scholar]
  • 40.Corbeil RR, Searle SR. Restricted maximum likelihood (REML) estimation of variance components in the mixed model. Technometrics. 1976;18(1):31-38. doi: 10.2307/1267913 [DOI] [Google Scholar]
  • 41.Goldberg AE, Ross LE, Manley MH, Mohr JJ. Male-partnered sexual minority women: sexual identity disclosure to health care providers during the perinatal period. Psychol Sex Orientat Gend Divers. 2017;4(1):105-114. doi: 10.1037/sgd0000215 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Hawn T. Invisible grief: pregnancy loss in trans and gender expansive people. Pregnancy Loss and Infant Death Alliance webinar. July 28, 2022. Accessed July 28, 2022. https://www.plida.org/index.php?option=com_content&view=article&id=128:july-28-webinar&catid=20:site-content
  • 43.Rioux C, Weedon S, London-Nadeau K, et al. Gender-inclusive writing for epidemiological research on pregnancy. J Epidemiol Community Health. 2022;76(9):823-827. doi: 10.1136/jech-2022-219172 [DOI] [PubMed] [Google Scholar]
  • 44.Spock A, Popkin R, Barnhart C. Strategies to improve measurement of sexual orientation and gender identity among youth. J Adolesc Health. 2022;71(6):662-664. doi: 10.1016/j.jadohealth.2022.09.009 [DOI] [PubMed] [Google Scholar]
  • 45.Di Florio A, Putnam K, Altemus M, et al. The impact of education, country, race and ethnicity on the self-report of postpartum depression using the Edinburgh Postnatal Depression Scale. Psychol Med. 2017;47(5):787-799. doi: 10.1017/S0033291716002087 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Flanders CE, Gibson MF, Goldberg AE, Ross LE. Postpartum depression among visible and invisible sexual minority women: a pilot study. Arch Womens Ment Health. 2016;19(2):299-305. doi: 10.1007/s00737-015-0566-4 [DOI] [PubMed] [Google Scholar]
  • 47.Goldberg AE, Smith JZ, Ross LE. Postpartum depression and anxiety in male-partnered and female-partnered sexual minority women: a longitudinal study. In: Liu H, Reczek C, Wilkinson L, eds. Marriage and Health. Rutgers University Press; 2020:53-70. doi: 10.36019/9781978803527-007 [DOI] [Google Scholar]
  • 48.Rice C, Ingram E, O’Mahen H. A qualitative study of the impact of peer support on women’s mental health treatment experiences during the perinatal period. BMC Pregnancy Childbirth. 2022;22(1):689. doi: 10.1186/s12884-022-04959-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Darwin Z, Greenfield M. Mothers and others: the invisibility of LGBTQ people in reproductive and infant psychology. J Reprod Infant Psychol. 2019;37(4):341-343. doi: 10.1080/02646838.2019.1649919 [DOI] [PubMed] [Google Scholar]
  • 50.Patel S, Sweeney LB. Maternal health in the transgender population. J Womens Health (Larchmt). 2021;30(2):253-259. doi: 10.1089/jwh.2020.8880 [DOI] [PubMed] [Google Scholar]
  • 51.Britt R, Burkhard J. U.S. maternal depression screening rates released for the first time through HEDIS. Policy Center for Maternal Mental Health. November 14, 2022. Accessed February 8, 2023. https://www.2020mom.org/blog/2022/11/14/us-maternal-depression-screening-rates-released-for-the-first-time-through-hedis
  • 52.Linares DE, Azuine RE, Singh GK. Social determinants of health associated with mental health among U.S. mothers with children aged 0–5 years. J Womens Health (Larchmt). 2020;29(8):1039-1051. doi: 10.1089/jwh.2019.8111 [DOI] [PubMed] [Google Scholar]
  • 53.Assari S. Social determinants of depression: the intersections of race, gender, and socioeconomic status. Brain Sci. 2017;7(12):156. doi: 10.3390/brainsci7120156 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54.Crenshaw K. On Intersectionality: Essential Writings. The New Press; 2019. [Google Scholar]
  • 55.Hoang TMH, Wong A. Exploring the application of intersectionality as a path toward equity in perinatal health: a scoping review. Int J Environ Res Public Health. 2022;20(1):685. doi: 10.3390/ijerph20010685 [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

eTable 1. Descriptive Statistics of Prenatal Visits, PHQ-9 Screenings, and PHQ-9 Scores, Split by Sexual Orientation and Race and Ethnicity

eTable 2. Descriptive Statistics of Postpartum Visits, PHQ-9 Screenings, and PHQ-9 Scores, Split by Sexual Orientation and Race and Ethnicity

Click here for additional data file. (95.7KB, pdf)
Supplement 2.

Data Sharing Statement

Click here for additional data file. (13.3KB, pdf)

Articles from JAMA Psychiatry are provided here courtesy of American Medical Association

RESOURCES