RACIAL DISPARITIES IN ACCESS TO INFERTILITY CARE IN A STATE WITH MANDATED INFERTILITY COVERAGE

Abstract

To investigate how race affects access to infertility care in a state with comprehensive, mandated insurance coverage for infertility services. All women seen in consult with a diagnosis of infertility at a large, academic affiliated center from January 2010 to December 2020 were included in the study. Patient age, partner age, marital status, and length of infertility at the time of initial consult were collected. Treatment utilization was determined by whether a patient underwent one or more intrauterine insemination (IUI) and/or in vitro fertilization (IVF) cycles. Race was categorized according to the U.S. Census Bureau standards which requires five minimum categories for race: “American Indian or Alaskan Native”, “Asian”, “Black”, “Native Hawaiian or Other Pacific Islander”, and “White”. Patients selecting more than one race were classified as “Two or more races”. Missing racial demographics were imputed from parental ancestry when available and patients were excluded if direct imputation was not possible. Access to care variables were compared between the racial groups using chi-square and t-test for parametric categorical and continuous variables, respectively. A total of 20,774 women met the study criteria of which 964 (4.6%) were Black, 26 (0.1%) American Indian or Alaskan Native, 2,491 (12.0%) Asian, 13 (0.1%) Native Hawaiian or other Pacific Islander, 17,098 (82.3%) White and 182 (0.9%) Two or more races. At the time of initial consult, Black women were older (36.3 vs. 34.9 years old, p<0.001) and had a longer duration of infertility (21.8 months vs. 18.2 months, p<0.001) as compared to White women. Additionally, Black women were more likely to self-pay for services (relative risk [RR] 3.0, 95% CI 2.3-3.9) and they pursued infertility treatment less frequently (RR 0.73, 95%CI 0.67-0.80 for IVF). There was no significant increase in consults among Black women over the study period (p=0.903). In contrast, the proportion of women presenting to care who identify as two or more races has increased over time (p<0.001). This group is still less likely to pursue infertility treatment compared to White women (RR 0.77, 95%CI 0.63-0.95 for IVF). The proportion of Asian women presenting to care has increased over time (p=0.003) however there remains a greater delay to infertility consult as compared to White women (19.9 vs. 18.2 months trying to conceive, p<0.001). Race impacts patient age and infertility duration at the time of initial infertility consult, as well as access to consults and infertility treatment utilization. These inequities are particularly pronounced in Black women and in women who identify with two or more races. The collection of accurate, standardized race and ethnicity data is an essential step in identifying and addressing the root causes of these health inequities.