Sexual Orientation–Related Disparities in Neonatal Outcomes

Understanding and addressing disparities among sexually minoritized birthing people is critical to ensuring equitable health care for all. In the December 2024 issue, Chakraborty et al1 describe how a combined group of sexually minoritized birthing people have a higher risk of preterm birth and low birth weight compared with heterosexual individuals. However, this analysis does not account for how patients became pregnant, a factor that is a critical consideration when caring for patients in the lesbian, gay, bisexual, and other sexually minoritized (LGB+) community. Assisted reproductive technology (ART), especially in vitro fertilization, is associated with an increased risk in preterm birth and low birth weight. Further, we know that patients who belong to sexual minority groups are much more likely to use these services for family building. In this study, there is no report of what proportion of patients used ART to become pregnant. The authors state that ART use was not addressed in this analysis because it is likely a mediator of the association. Although it is true that how a patient becomes pregnant is unquestionably a factor on the causal pathway between sexual orientation and neonatal outcomes, accounting for it is critical for productively advancing our understanding of sources of disparities. If the authors' goal is to simply show that LGB+ birthing people have a higher rate of some adverse birth outcomes, they do just that. However, the more important and informative analysis would be to stratify by mode of becoming pregnant to see where disparities in birth outcomes persist. Only once that is done can we truly move closer to uncovering actionable sources of inequality and take steps toward rectifying them.