Infertility in the Midwest: Perceptions and Attitudes of Current Treatment

Am J Obstet Gynecol. 2021 Feb 19;S0002-9378(21)00104-6. doi: 10.1016/j.ajog.2021.02.015. Online ahead of print.

Abstract

Background: Though infertility affects an estimated 6.1 million individuals in the United States, only half of those individuals seek fertility treatment and the majority of those patients are white and of high socioeconomic status. Research has shown that insurance mandates are not enough to ensure equal access. Many workplaces, schools and medical education programs have made efforts in recent years to improve the cultural humility of providers in efforts to engage more racially and economically underrepresented groups in medical care. However, these efforts have not been assessed on a population of patients receiving fertility care, an experience that is uniquely shaped by individual social, cultural and economic factors.

Objective: To better understand the racial, cultural, economic and religious factors that impact patient experiences obtaining fertility care.

Study design: A cross-sectional self-administered survey was administered at an academic fertility center in Chicago, Illinois. Of 5,000 consecutive fertility care patients, 1,460 completed the survey and were included in the study sample. No interventions were used. Descriptive univariate frequencies and percentages were calculated to summarize sociodemographic and other relevant patient characteristics (e.g. race/ethnicity, age, household income, religious affiliation, insurance coverage). Rates of endorsing perceived physician cultural competency were compared among demographic subgroups using Pearson Chi-Squared tests with two-sided p<.05 indicative of statistical significance. To identify key determinants of patient-reported worry regarding nine different fertility treatment outcomes and related concerns, a series of multiple logistic regression models were fit to examine factors associated with patient-report of being "very worried" or "extremely worried".

Results: Members of our sample (N=1460) were between 20 and 58 years (Meanadjusted=36.2, SD=4.4). Among Black participants, 42.3% reported that their physician does not understand their cultural background, compared to 16.5% of white participants (p<0.0001). Participants that identified as Latinx were significantly more likely than white participants to report being very/extremely worried about side-effects of treatment, a miscarriage, ectopic pregnancies, and birth defects (p<0.05, 0.02, 0.002, 0.001, respectively). Individuals that identify as Hindu were nearly 4 times more likely to report being very/extremely worried about experiencing an ectopic pregnancy than non-religious participants (p<0.0002). Respondents most strongly identified the biology or physiology of the couple (Meanadjusted: 21.6, CI: 20.4-22.7) and timing or age (Meanadjusted: 27.8, CI: 26.5-29.1) as being associated with fertility. Overall, respondents most strongly disagreed that the ability to bear children rests upon God's will (Meanadjusted: 65.4, CI: 63.7-67.1), which differed most significantly by race (p<0.0001) and religion (p<0.0001).

Conclusion: Of patient characteristics investigated, racial and ethnic subgroups showed the greatest degree of variation in regard to worries and concerns surrounding the experience of fertility treatment. Our findings emphasize a need for improved cultural humility on behalf of physicians, in addition to affordable psychological support for all patients seeking fertility care.

Keywords: Cultural competency; IVF; disparities; ethnicity; fertility treatment; race; religion; socioeconomic status.