(WITHDRAWN) Intersectional Analysis of Predictors of Prenatal Postpartum Depression Among Sexual Minority Women: Prenatal Psychological Distress and the Moderating Role of Race/Ethnicity

Background & Purpose: Despite well documented perinatal health outcome disparities among pregnant sexual minority women (PSMW), research exploring their mental health is more limited. PSMW with racial/ethnic minority identities may experience multiple minority status, putting them at greater risk for poor perinatal mental health. Prenatal psychological distress (PrePD) has been found to predict postpartum depression (PPD), a common and serious complication of pregnancy. Small-scale studies find elevated rates of PPD for SMW as compared to heterosexual women, with higher PPD symptomatology amongst bisexuals. Elevated rates of PPD have also been found by race, with non-Hispanic Black, Asian, and Hispanic women experiencing higher rates of PPD than whites. This study aimed to address two questions: Does PrePD vary by sexual orientation and race/ethnicity? and; Does race/ethnicity moderate the relationship between sexual orientation and PrePD?

Methods: This study used data from the 2017-2020 Behavioral Risk Factor Surveillance System, a cross-sectional nationally representative survey of non-institutionalized US adult (18+ years of age) civilians. Data from self-identified PSMW (N=407) and heterosexual women (N=5105) reporting a past-year pregnancy formed the analytic sample. Sexual orientation, the primary independent variable, was self-reported as “Straight”, “Lesbian/Gay”, “Bisexual”, or “Other.” PrePD, the primary outcome variable, was measured ordinally by self-reported number of poor mental health days – 0, 1-13, >14 – within the last month. We estimated ordinal logistic regressions to explore the relationships among sexual orientation, race, and PrePD, adjusting for general health, chronic disease, and other established PPD risk factors: depression history, age, parity, gestational diabetes, marital status, family income, education level.

Results: The proportion of PSMW reporting 14-30 poor mental health days/month was 2-3 times greater than pregnant heterosexuals (11% Straight; 20% Lesbian/Gay; 31% Bisexuals; 24% Other). Bisexual SMW were more likely (aOR=1.06, p<0.001) than heterosexuals to report PrePD, however, no significant differences were noted between Lesbian/Gay or Other-identified SMW and heterosexual women. Black Non-Hispanic (aOR=-0.23, p<0.05), Hispanic (aOR=-0.33, p<0.001), and Other non-Hispanic women (aOR=-0.43, p<0.001) were less likely than whites to report PrePD. Race/ethnicity was not found to moderate the relationship between sexual orientation and PrePD.

Conclusions & Implications: Differences in PrePD among PSMW parallel findings in the literature, with bisexual women experiencing significantly poorer perinatal mental health than heterosexuals. This finding underlines the need for perinatal social workers and other care providers to identify and screen bisexual women for mental health disturbance in pregnancy. Paradoxically, racial minorities were found to be less likely than whites to report PrePD. Similarly, lesbians and other-identified SMW were no more likely to report PrePD than heterosexuals. A major implication of these counterintuitive findings is the need for additional research: Do racial minorities and lesbians have unique or additional mental health protective factors during pregnancy or, do these findings reflect differences in help-seeking behaviors during pregnancy? To develop programs and policies that effectively address perinatal risk and symptomatology, future research should identify unique and common risk factors for prenatal and postpartum mental health disturbance amongst SMW, racial minorities, and women with multiple minority identities.