Women's perceived experiences of abuse in the health care system: their relationship to childhood abuse

OBJECTIVES: The aim of this study was to determine whether there was an association between any lifetime experiences of emotional, physical and/or sexual abuse and perceived abuse in the health care system. Furthermore, we wanted to ascertain if adult victims of perceived abuse in the health care system reported exposure to childhood emotional, physical and/or sexual abuse more often than non-victims did. DESIGN: A cross sectional questionnaire study. The first hypothesis was tested in the total sample, and the second hypothesis in a case-control analysis. The cases were those women who reported perceived experiences of abuse in the health care system as adults. Exposure was defined as experience of emotional, physical and/or sexual abuse in childhood. SETTINGS: Three Swedish gynaecological clinics. SAMPLE: A total of 2439 gynaecology patients (response rate 81%). METHODS: Postal questionnaire. MAIN OUTCOME MEASURE: Associations between experiences of emotional, physical and/or sexual abuse, and perceived abuse in the health care system; all operationalised in The NorVold Abuse Questionnaire (NorAQ). RESULTS: A general association was found between lifetime experiences of emotional, physical and/or sexual abuse and perceived abuse in the health care system. Adult victims of abuse in the health care system reported experiences of emotional, physical and/or sexual abuse in childhood more often than non-victims did. These findings also held after adjustment for age and educational level. CONCLUSIONS: We found associations between experiences of any lifetime abuse and perceived abuse in the health care system. Adult victimisation in the health care system was associated with childhood exposure to emotional, physical and/or sexual abuse. These associations call for attention and need to be further investigated.     

Patients' experiences of abuse in health care: a Nordic study on prevalence and associated factors in gynecological patients

BACKGROUND: In an earlier Swedish study conducted with The NorVold Abuse Questionnaire, we found that one-third of female patients who had experienced adult abuse in health care (AAHC) had a background of childhood emotional, physical and/or sexual abuse (EPSA) ('revictimised'). But since the majority of women with AAHC were 'new victims' without such a background, there might be other factors associated with AAHC. The present study aimed to map prevalence of abuse in health care (AHC), and associated variables among new victims and revictimised patients. METHODS: We carried out a cross-sectional questionnaire study at 5 Nordic gynecological clinics. Associations between AAHC and other variables were tested in a multivariate model in 4 groups of women with adult EPSA, childhood EPSA, childhood and adult EPSA, and no EPSA. RESULTS: The response rate was 77% (n=3,641). The overall prevalence of any lifetime experience of AHC was 13-28%. High educational level, physical complaints, post-traumatic stress symptoms, and sleeping problems were associated with AAHC in women without EPSA (new victims). Poor self-rated health was strongly associated with AAHC in the 3 groups of women with EPSA. CONCLUSION: AHC is commonly reported by gynecological patients in the Nordic countries, but not yet properly explored or understood. The most important factors associated with AAHC were high educational level and poor self-rated health.     

Childhood Abuse and Fear of Childbirth—A Population‐based Study

Abstract: Background: Childhood abuse affects adult health. The objective of this study was to examine the association between a self‐reported history of childhood abuse and fear of childbirth. Methods: A population‐based, cross‐sectional study was conducted of 2,365 pregnant women at five obstetrical departments in Norway. We measured childhood abuse using the Norvold Abuse Questionnaire and fear of childbirth using the Wijma Delivery Expectancy Questionnaire. Severe fear of childbirth was defined as a Wijma Delivery Expectancy Questionnaire score of ≥85. Results: Of all women, 566 (23.9%) had experienced any childhood abuse, 257 (10.9%) had experienced emotional abuse, 260 (11%) physical abuse, and 290 (12.3%) sexual abuse. Women with a history of childhood abuse reported severe fear of childbirth significantly more often than those without a history of childhood abuse, 18 percent versus 10 percent (p = 0.001). The association between a history of childhood abuse and severe fear of childbirth remained significant after adjustment for confounding factors for primiparas (adjusted OR: 2.00; 95% CI: 1.30–3.08) but lost its significance for multiparas (adjusted OR: 1.17; 95% CI: 0.76–1.80). The factor with the strongest association with severe fear of childbirth among multiparas was a negative birth experience (adjusted OR: 5.50; 95% CI: 3.77–8.01). Conclusions: A history of childhood abuse significantly increased the risk of experiencing severe fear of childbirth among primiparas. Fear of childbirth among multiparas was most strongly associated with a negative birth experience. (BIRTH 37:4 December 2010)     

Prevalence of sexual abuse among women seeking gynecologic care in Germany

OBJECTIVE: To estimate the prevalence of sexual abuse among patients seen for gynecologic care in Germany. METHODS: A short anonymous questionnaire was distributed to 1157 women attending a gynecologic outpatient clinic at a large urban teaching hospital. Data collected using the questionnaire included patient characteristics, sexual abuse history, and screening practices. Women who reported that they had been abused were asked if they had ever discussed the issue with their gynecologist. RESULTS: A total of 1075 questionnaires were returned, for a response rate of 92.9%. Almost half (n = 479 [44.6%]) of the women surveyed reported that they had been the subject of unwanted sexual attention. One fifth (n = 216 [20.1%]) had been forced to engage in sexual activities: 6.8% in childhood, 10.3% during adolescence, 6.4% as an adult, and 3.5% across more than one stage. Thirteen women (6%) reported having discussed the abuse with their gynecologist. Sixty-six (30.5%) were too afraid to raise the issue, and 119 (55.1%) stated it was not relevant to their care. Only one woman (0.5%) reported that her gynecologist had asked about sexual abuse. CONCLUSION: Despite the high prevalence of sexual abuse among women seeking gynecologic care, routine screening does not appear to be part of standardized practice.     

Sexual abuse and reproductive health among unmarried young women seeking abortion in China.

OBJECTIVE: To investigate sexual violence and its impact on reproductive health in unmarried young women seeking abortion in China. METHODS: A total of 2002 participants were surveyed by questionnaire, gynecologic examination, and laboratory tests for sexually transmitted disease (STD). RESULTS: Overall, 14% of participants had experienced sexual violence and 43.4% were diagnosed with STD. Among victims of sexual abuse, 8.6% had their first sexual encounter when they were younger than 18 years; 42.7% had had 2 or more sexual partners; and 21.6% never used contraception. Multivariate analysis revealed that sexual abuse, multiple sexual partners, sexual activity before the age of 18 years, and not using contraception were important indicators of the presence of STD. CONCLUSION: The prevalence of sexual abuse is high in China; and among unmarried young women seeking abortion, those who experience sexual abuse are at significantly increased risk for STD.     

1099名大学生儿童期性虐待的调查与分析

目的:探讨大学生中儿童期性虐待的发生状况,为保障儿童免受性虐待制定预防对策提供参考依据。方法:使用电子问卷在上海市4所大学对1099名大学生开展儿童期性虐待经历情况的匿名调查。结果:15.1%(男生10.2%、女生18.2%)的大学生在14岁前至少经历过1种或几种不同形式的身体接触或非身体接触的性虐待,1.2%的人曾被试图性交或肛交,0.8%的人曾被强行性交或肛交。施虐者主要是陌生人(40.3%)和同学/朋友(23.9%),还有11.3%为家庭成员或亲戚。来自城市的女大学生比来自城镇和农村者遭受儿童期性虐待的比例更高。未显示父母的文化程度与儿童期性虐待的发生有关联。经历过儿童期性虐待的对象以后发生性行为和强迫性行为的危险更高。结论:在大学生中儿童期性虐待问题较常见,且与以后的高危性行为相关,应加强对这一问题的关注并采取相应的预防措施。     

A survey of pregnant women's knowledge about sexual abuse

STUDY OBJECTIVE: To assess pregnant women's understanding of sexual abuse prevalence and perpetrator characteristics. DESIGN: A multiple choice questionnaire concerning knowledge about sexual abuse prevalence and an understanding of potential perpetrators was presented to patients. Comparisons were made based on participant's age, educational status, and personal involvement in the care of children. SETTING: Prenatal clinic, Department of OB/GYN, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee. PARTICIPANTS: Patients presenting for new obstetrical evaluation (N = 289). MAIN OUTCOME MEASURES: Responses to the questionnaire. RESULTS: Less than half of the subjects correctly answered questions about sexual abuse prevalence. Only 22% of patients understood the potential youthfulness of juvenile sex offenders. Neither age nor child care responsibilities affected response. Subjects with greater than 12 years of formal education achieved significantly higher scores than those with less education, 59% of respondents were interested in more information. CONCLUSION: Pregnant women's knowledge about the dangers of sexual abuse was suboptimal in this population. The majority of patients were interested in more information.     

Gynaecological symptoms associated with physical and sexual violence

OBJECTIVE: The study aims to describe the prevalence of violent physical and sexual experiences in female outpatients and to identify specific gynaecological symptoms that are associated with a history of abuse. STUDY DESIGN: We performed a cross-sectional study among native German women. The confidential self-administered questionnaire included items on physical and sexual abuse and on the patient's medical history. Of a total of 1941 eligible women, 730 (37.6%) participated in the survey. We calculated prevalence rates of physical and sexual abuse and compared victims and non-victims of violence with respect to specific symptoms and complaints. We developed multivariate models for pelvic pain and vaginal infection. RESULTS: The lifetime prevalence of severe physical violence by any kind of perpetrator was 35.5%. 13.5% of participants reported a completed rape. The lifetime prevalence of physical and/or sexual intimate partner violence (IPV) was 28.3%. Physical and sexual abuse is significantly associated with irregular menstrual cycle, urinary tract infections and pelvic pain independent of menses. CONCLUSIONS: Physical and sexual violence are associated with many gynecological symptoms. Especially gynecologists and general practitioners have to be aware that their patients might be victims of violence. This is important for adequate diagnosis and therapy and to avoid retraumatization in affected women.     

Experiences of physical and sexual abuse and their implications for current health

OBJECTIVE: To estimate the prevalence of a history of physical and sexual abuse in adulthood among gynecological patients and the association with general and reproductive health. METHODS: A cross-sectional questionnaire study on abusive experiences of gynecologic outpatients in a tertiary hospital. The total sample size was 691. RESULTS: Of all women, 42.4% had experienced moderate or severe physical or sexual abuse as an adult. One hundred forty-seven (21.6%) women reported physical abuse, 84 (12.3%) sexual abuse, and 58 (8.5%) both. The abused and nonabused women did not differ in mean age, education, or parity. Sexually abused women and those who were both sexually and physically abused reported poor general health significantly more often (P=.005 and P=.001, respectively) than the nonabused. They also rated their sex life as significantly worse than the nonabused women (P=.002 and P=.012, respectively). Over half of abused women had experienced common physical complaints during the previous 12 months compared with one third of the nonabused (P<.001). Two thirds of both the abused and the nonabused women preferred that their gynecologist not ask directly about abuse. CONCLUSION: Abusive experiences were common in gynecologic outpatients. Women with abusive experiences had ill health and poor sexual life more often than the controls. In contrast to the results of previous studies, most of the women did not want to be asked about abuse by their gynecologist.     

The association of sexual abuse with pelvic pain complaints in a primary care population

OBJECTIVE: Our purpose was to determine the prevalence of sexual abuse during childhood and adulthood and its association with pelvic and other pain complaints in a population of reproductive-aged women. STUDY DESIGN: A 10-page questionnaire was administered to 581 nonpregnant women aged 18 to 45 years examined in primary care offices. RESULTS: The reported incidences of childhood and adult sexual abuse were 26% and 28%. In regression analyses, with the exception of irritable bowel syndrome, women with only a history of childhood sexual abuse and no abuse later in life are not more likely than nonabused women to report pain syndromes. By contrast, with the exception of dysmenorrhea, all pain complaints studied were more common in women reporting abuse both as children and as adults. CONCLUSIONS: Sexual abuse that occurs during childhood and again as an adult is strongly associated with pelvic pain complaints.(Am J Obstet Gynecol 1997;177:12)     

Sexual violence in women's lives. Findings from the Women's Safety Project,a community-based survey

This paper presents a community-based study, which aims to determine the interconnections between women's experiences of sexual abuse in childhood, sexual assault in adulthood, and physical assault in intimate relationships in Toronto, Canada. An in-depth face-to-face interview was conducted with 420 women who comprised the random sample of the women living in Toronto, Canada. Findings on the prevalence and effects of various forms of sexual abuse and violence revealed that 97.6% of the woman interviewed reported that they personally experienced some form of sexual violation. Sexual abuse in childhood (including incest), sexual assault, sexual harassment, and physical assault in intimate relationships were documented. Among the findings were that one-fourth of the women in the sample were physically assaulted by a male intimate, one-half of the women reported being raped or almost raped, and nearly half of the respondents reported experiencing some kind of sexual abuse before reaching age 16.     

Are sociodemographic and regional and sample factors associated with prevalence of abuse?

BACKGROUND: The aims of the present study were: 1) to estimate the prevalence of emotional, physical and sexual abuse and abuse in the health care system, and 2) to study the associations between prevalence of abuse and sociodemographic and sample variables. METHODS: This cross-sectional study used a validated postal questionnaire in four Swedish samples; patients at three gynecologic clinics with different character and in different regions (n = 2439) and women in one randomized population sample (n = 1168). RESULTS: Any lifetime emotional abuse was reported by 16.8-21.4% of the women; physical abuse by 32.1-37.5%; sexual abuse by 15.9-17.0%; and abuse in the health care system by 14.0-19.7%. For 7-8% abuse had included life threats and 9-20% of all women in the study currently suffered from their experiences of abuse. Most women had not disclosed their background of abuse to the gynecologist. There were differences in sociodemographic variables between the four samples. Generally, in the multivariate analyses we found associations between prevalence of abuse and age, educational level, civil status and occupation, but no consistent association between prevalence of abuse and sample variables. CONCLUSION: Lifetime prevalence rates of the four kinds of abuse were high in all samples as measured by the NorVold Abuse Questionnaire (NorAQ), and 1/10-1/5 women in the study suffered currently from abusive experiences. In multivariate analyses prevalence of abuse was consistently associated with sociodemographic but not to sample variables.     

Domestic violence, lifetime trauma and psychological health of childbearing women

OBJECTIVE: Although histories of abuse are associated with psychiatric illness in women, health professionals rarely enquire directly about such experiences. This study examined the association between physical and sexual violence and lifetime trauma and depressive and posttraumatic stress symptoms in women receiving maternity care. DESIGN: Cross sectional study. SETTING: South London Hospital maternity services. POPULATION: Two hundred women receiving postnatal or antenatal care. METHODS: Two hundred women receiving postnatal or antenatal care at a South London maternity service were screened for lifetime experiences of trauma and domestic violence. Information was obtained about self-harming behaviour, suicidal thoughts and attempts and psychiatric history. Women completed the Edinburgh Postnatal Depression Scale (EPDS) and the Posttraumatic Diagnostic Scale (PTDS). MAIN OUTCOME MEASURES: RESULTS: One hundred and twenty-one (60.5%) women reported at least one traumatic event and two-thirds of these had experienced multiple traumatic events. The most frequent (34%) was witnessing or experiencing physical assault by a family member. Forty-seven (23.5%) women had experienced domestic violence. Physical and sexual abuse commonly co-occurred. Thirteen (10.7%) women with a trauma history had current posttraumatic stress disorder. Severe posttraumatic symptoms were associated with physical and sexual abuse histories and repeat victimisation. Adult and childhood physical and sexual abuse histories were also associated with more severe depressive symptomatology. Significant social factors associated with depression were being single, separated or in a non-cohabiting relationship. CONCLUSION: Traumatic events are under-recognised risk factors in the development of depressive and posttraumatic stress symptoms in childbearing women. Childhood abuse creates a vulnerability to re-traumatisation in adulthood. Awareness of the impact of trauma and abuse on psychological health may enable more appropriate targeting of clinical services and support for women receiving maternity care.     

Bad experience, good birthing: Dutch low-risk pregnant women with a history of sexual abuse

OBJECTIVE: The long-term effects on women in childbirth with a history of sexual abuse have only been studied to a limited degree. We estimated the prevalence of lifetime experience among low-risk pregnant women (non-clinical) in The Netherlands as well as the association with (1) psycho-social outcomes, and (2) the birth process. METHODS: Study of 625 randomly selected low-risk pregnant women. At 20-24 weeks gestation, participants completed a questionnaire covering socio-demographic variables, sexual attitude, and psychological determinants. Midwives recorded details of the birth process. RESULTS: Nearly one-in-nine (11.2%) women had experienced sexual abuse. They were on average younger, more likely to smoke, and had lower household income. They reported more conflicting feelings about sex than women who did not report a history of abuse (p = 0.02). Multiparous women with a history of sexual abuse reported more emotional distress (p = 0.037), more internal beliefs concerning health (p = 0.004), and they were also more likely to suffer pelvic pain (p = 0.045). Sexually-abused women reported higher levels of autonomy (p = < 0.001). Referral rates to secondary care were equal. Sexually-abused women were less likely to receive episiotomies (p < 0.005). CONCLUSION: Little difference was observed in major birth-related technical interventions between women with and without a history of sexual abuse.     

Disclosure and health-seeking behaviour following intimate partner violence before and during pregnancy in Flanders, Belgium: a survey surveillance study

OBJECTIVES: The objectives were to estimate the prevalence of physical and sexual intimate partner violence (IPV) among a regional sample of the general obstetric population as the lifetime prevalence, as the 1-year period prevalence before pregnancy, and as the prevalence during the index pregnancy; to assess the rates of disclosure and help-seeking behaviour with IPV; and to determine the acceptability of screening for IPV. STUDY DESIGN: A multi-centred survey surveillance study was carried out among pregnant women attending five large hospitals in the province of East Flanders, Belgium as a regional probability sample of the general obstetric population. Data were collected through an anonymous, written questionnaire that included the Abuse Assessment Screen and additional questions on the circumstances of the most recent episode of physical or sexual violence, on disclosure and help-seeking behaviour, on reporting assault to the police, and on the acceptability of routine screening for IPV. RESULTS: The sampling frame consisted of 1362 women who received the questionnaire at the antenatal service during a 2-month study period, of which 537 (mean age 29.4 years, S.D. 4.09) returned the envelope (response rate 39.4%). The lifetime prevalence of IPV was estimated to be 10.1% (95% CI 7.7-13.0%) and the period prevalence of IPV during pregnancy and/or in the year preceding pregnancy 3.4% (95% CI 2.1-5.4%). There was a significant difference in the reported lifetime prevalence of IPV between women attending with a partner and those who came to the prenatal visit unattended by their partner in particular (6.8% versus 13.9%, p=0.010). Overall, only 19.2% (23 out of 120) and as few as 6.6% (4 out of 61) of the victims of physical and sexual abuse respectively sought medical care by consulting a general practitioner, gynaecologist, or an emergency department. Routine screening for IPV by a general practitioner or gynaecologist was found to be largely acceptable. CONCLUSIONS: In our highly medicalised society, women experiencing partner violence rarely disclose abuse to the widely available health care services, unless they are directly asked about it, which appears an acceptable practice. Hence, there is a definite need to improve women's awareness regarding abuse and their help-seeking behaviour at a public health level.     

Adverse childhood experiences and risk of paternity in teen pregnancy

OBJECTIVE: Few studies have investigated risk factors that predispose males to be involved in teen pregnancies. To provide new information on such factors, we examined the relationships of eight common adverse childhood experiences to a male's risk of impregnating a teenager. METHODS: We conducted a retrospective cohort study using questionnaire responses from 7399 men who visited a primary care clinic of a large health maintenance organization in California. Data included age of the youngest female ever impregnated; the man's own age at the time; his history of childhood emotional, physical, or sexual abuse; having a battered mother; parental separation or divorce; and having household members who were substance abusers, mentally ill, or criminals. Odds ratios (ORs) for the risk of involvement in a teen pregnancy were adjusted for age, race, and education. RESULTS: At least one adverse childhood experience was reported by 63% of participants, and 34% had at least two adverse childhood experiences; 19% of men had been involved in a teen pregnancy. Each adverse childhood experience was positively associated with impregnating a teenager, with ORs ranging from 1.2 (sexual abuse) to 1.8 (criminal in home). We found strong graded relationships (P <.001) between the number of adverse childhood experiences and the risk of involvement in a teen pregnancy for each of four birth cohorts during the last century. Compared with males with no adverse childhood experiences, a male with at least five adverse childhood experiences had an OR of 2.6 (95% confidence interval [CI] 2.0, 3.4) for impregnating a teenager. The magnitude of the ORs for the adverse childhood experiences was reduced 64-100% by adjustment for potential intermediate variables (age at first intercourse, number of sexual partners, having a sexually transmitted disease, and alcohol or drug abuse) that also exhibited a strong graded relationship to adverse childhood experiences. CONCLUSION: Adverse childhood experiences have an important relationship to male involvement in teen pregnancy. This relationship has persisted throughout four successive birth cohorts dating back to 1900-1929, suggesting that the effects of adverse childhood experiences transcend changing sexual mores and contraceptive methods. Efforts to prevent teen pregnancy will likely benefit from preventing adverse childhood experiences and their associated effects on male behaviors that might mediate the increased risk of teen pregnancy.     

Childhood sexual abuse and the consequences in adult women

This paper reviews the literature on childhood sexual abuse and its implications for women. It is estimated that at least 15-38% of adults have been sexually abused as children, with figures higher for women than for men. Failure to report abuse is common, and only 20-50% of incidents may come to the attention of authorities. Although childhood sexual abuse is present in all socioeconomic groups, more severe forms of abuse appear to be associated with lower socioeconomic status. After the age of ten, a sharp increase is observed in vaginal intercourse, sexual assaults accompanied by physical violence, and abuse committed by strangers. Although fathers are frequently cited as the primary perpetrators, not all studies support this finding. Other relatives have been reported to account for 20-70% of the sexual abuse occurring within the family. A history of childhood abuse may contribute to sexual problems or multiple chronic complaints in the adult woman. Moreover, some of these women may experience depression, anxiety, and low self-esteem. The gynecologist should use empathetic questioning with all patients regarding abuse, and integrate the patient's history of abuse with current health care. Physicians who are uncomfortable with this topic or who observe ongoing distress in their patients should refer these women to a mental health practitioner who is familiar with the issues common to women who have experienced childhood sexual abuse.     

Risk of sexual dysfunction in a randomly selected nonclinical sample of the Swedish population

OBJECTIVE: To investigate the risk of sexual dysfunction as a result of childhood sexual abuse or sexual assault in a randomly selected nonclinical sample of men and women. METHODS: In 1996, a randomly selected sample of 2,810 Swedish males and females completed a 322-item interview and questionnaire. Age-adjusted odds ratios (ORs) were calculated to assess risk of sexual dysfunction and analysis of variance was employed to test differences by gender and abuse or assault history in regard to seeking assistance for sexual dysfunction. RESULTS: For females with a history of childhood sexual abuse, an increased risk of anorgasmia for more than 12 months was found for women aged between 31 and 45 years (OR 1.21, P=.009). For females with a history of sexual assault; an increased risk for hypoactive sexual desire disorder was found for women who between the ages of 16 and 30 years (OR 1.51, P=.03), 31 and 45 years (OR 1.28; P=.02), 46 and 60 years (OR 1.21, P=.03), and 61 and 84 years (OR 1.62, P=.04); lubrication problems in the past year for women between 46 and 60 years (OR 1.28, P=.02) and for more than 12 months (OR 1.38, P=.02). No statistically significant increased risk of sexual dysfunction was found for males with a history of childhood sexual abuse. Males who reported a history of sexual assault as an adult had a significant increased risk of retarded ejaculation in the last 12 months if they were between the ages of 31 and 45 years (OR 2.00, P=.008) or 46 and 60 years (OR 2.11, P=.02). Women most often reported sexual dysfunction to their gynecologists (18%) or midwives (8.4%), whereas men reported their sexual dysfunction to their physicians (5.6%) or urologists (4.3%). CONCLUSION: Future research should focus on predictors of sexual dysfunction and resilience subsequent to childhood sexual abuse and sexual assault as an adult. LEVEL OF EVIDENCE: III.     

Lesbian mothers. Health care experiences

A self-administered questionnaire was completed by 35 women who had delivered within the last five years and were self-identified lesbians when they conceived. The majority of women conceived through donor insemination and used the medical care system to achieve pregnancy. All sought prenatal care within the first 16 weeks, 89% participated in childbirth classes, and 80% breastfed for six months or more. Over half of the women (51%) sought obstetrical care from physicians, while 49% selected midwives. The majority (91%) disclosed their sexual orientation to their provider. Overall the women described their experience with obstetrical care providers as positive. However, a greater percentage of women who selected midwives reported higher levels of support from and satisfaction with their provider compared to those who selected physicians.     

LESBIAN MOTHERS

A self-administered questionnaire was completed by 35 women who had delivered within the last five years and were self-identified lesbians when they conceived. The majority of women conceived through donor insemination and used the medical care system to achieve pregnancy. All sought prenatal care within the first 16 weeks, 89% participated in childbirth classes, and 80% breastfed for six months or more. Over half of the women (51%) sought obstetrical care from physicians, while 49% selected midwives. The majority (91%) disclosed their sexual orientation to their provider. Overall the women described their experience with obstetrical care providers as positive. However, a greater percentage of women who selected midwives reported higher levels of support from and satisfaction with their provider compared to those who selected physicians.