Determinants of utilization of infertility services by race and ethnicity in a state with a comprehensive infertility mandate

Abstract

To examine the association between sociodemographic factors and utilization of infertility services by race and ethnicity in a state with a comprehensive infertility mandate. Retrospective cohort. Academic-affiliated fertility center. Women presenting for initial infertility evaluation from January 2010-December 2021. Initial infertility evaluation and treatment utilization. The prevalence of reproductive-aged women who reside in Massachusetts presenting for initial consult versus census-based estimates was calculated for each racial and ethnic group. Age at initial consult, insurance coverage, drive time to nearest affiliated center, and neighborhood deprivation as measured by Area Deprivation Index, were considered determinants of treatment utilization in regression analysis. A total of 16,160 women presenting for an infertility consult from 2010-2021 met inclusion criteria. Compared to census estimates, Non-Hispanic (NH) Asian and NH White individuals were overrepresented in initial consults, whereas the NH Black and Hispanic populations were underrepresented throughout the study period. Mean age at presentation was higher in NH Black women compared to the NH Asian reference group (35.7 ± 5.1 vs 34.6 ± 4.4 years old). A lower proportion of Hispanic and NH Black women had private insurance (78% and 79%, respectively) compared to 86% of NH Asian women. Over a fifth of Hispanic and NH Black women lived in the most disadvantaged ADI quintile (23 and 21%, respectively) compared to 6% of the reference population. Overall, the absence of private insurance, greater neighborhood disadvantage, and increased driving distance were associated with lower treatment utilization (OR 0.79, [95% confidence interval 0.71-0.87], for other vs. private insurance; OR 0.62, [0.53-0.72], for ADI quintile 5 vs. 1, OR 0.84 [0.72-0.97] for drive time 15-30 vs. <15 minutes), whereas age was not (OR 0.96 [0.93-1.00] for each 5-year increase). Relative to their numbers in the broader population of reproductive-aged women in Massachusetts, the NH Black and Hispanic populations were the most underrepresented racial and ethnic groups seen for infertility evaluation at our center. These individuals were less likely to have private insurance coverage and more likely to live in disadvantaged neighborhoods, which are variables that negatively impact infertility treatment utilization.