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INTRODUCTION: Sexual-minority women may have higher rates of adverse perinatal outcomes; however, population level maternal morbidity has not been studied in this group. METHODS: We conducted a cross-sectional study of birth certificates from Massachusetts (2012–2018) and Ohio (2016–2018). Within each state, women giving birth in same-sex marriages were compared to those in different-sex marriages. Outcomes included gestational hypertension or preeclampsia (GHTN/PEC), chronic hypertension, pregestational diabetes, and gestational diabetes. Chi-square tests were used for comparisons. Multivariable logistic regression was performed to control for age, parity, race, and socioeconomic status. RESULTS: Of the 315,432 and 323,841 birth records from married individuals in Massachusetts and Ohio, respectively, 1,997 (0.6%) and 1,677 (0.2%) were from those in same-sex marriages. In both states, women giving birth in same-sex marriages had higher rates of nulliparity, age over 35, obesity, and tobacco use. In Ohio they were more likely to be of Black race, lower education level, and utilizing WIC, but in Massachusetts they were more likely to be of White race, higher educational level, and not utilizing WIC. In both states, this population had higher rates of GHTN (3.5% versus 2.3%), PEC (11.8% versus 8.8%), and, in Massachusetts, chronic hypertension (3% versus 1.7%) (all P <.001). In the multivariable logistic regression models, the adjusted odds ratios of GHTN/PEC, chronic hypertension, pregestational diabetes, or gestational diabetes were similar between women in same-sex and different-sex marriages. CONCLUSION: In two large populations, women in same-sex marriages were significantly more likely to have GHTN/SPEC, but not after controlling for known risk factors, all of which were higher in this population. [ABSTRACT FROM AUTHOR]