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Who Can Afford a Baby? An Intersection of Gender, Race, and Class Oppression in Fertility Treatment

Updated: Jul 24, 2023

The World Health Organization (WHO) describes infertility as an inability to achieve a viable pregnancy within one year of regular and unprotected heterosexual sex. Infertility is classified as a disease by WHO and as a disability under the Americans with Disabilities Act (ADA). The Center for Disease Control estimates that 1 in 5 heterosexual women who have no prior births experience infertility. This makes infertility one of the most common diseases/disabilities in women of reproductive age (Insogna & Ginsburg, 2018; World Health Organization, 2018:2020; Davis & Khosla, 2020).


While treatment options are available, several factors determine the choice of treatment. First, the physician has to diagnose the cause of infertility. If the cause of infertility is traced to an abnormal hormone level, medications may be prescribed to regulate the hormone for the patient to get pregnant. Surgery may be recommended if there is an obstruction or growth in the reproductive organs. Sometimes, medications and/or surgery are insufficient to address the problem, so other interventions are needed to help the patient achieve pregnancy. Intrauterine insemination (IUI) or in-vitro fertilization (IVF) with or without a gestational carrier (surrogacy) may be recommended (Weigel et al., 2020). Often, patients try different combinations of interventions multiple times before a pregnancy is achieved (Weigel et al., 2020).


The second factor that determines treatment choice is cost and access to care. Assisted reproductive treatments and services are expensive, with out-of-pocket expenses for fertility medications costing up to thousands of dollars depending on the patient’s state, provider, and insurance plan (Insogna & Ginsburg, 2018). Fertility medications (pills and injections) induce ovulation by stimulating hormones and the maturation of ovarian eggs. These medications can be used to either directly resolve infertility or for in-vitro fertilization.


Compared to other medications on the market, Gonadotropins (injection) and Letrozole (a fertility pill) are preferred for their high success rates. Patients can pay between $10 to $6000 per cycle for fertility pills and injections, depending on insurance coverage, type of medication, and whether the drug is brand or generic. Fertility pills like clomiphene citrate, Letrozole, and metformin are cheaper but have a lower success rate than injections (National Institute of Health, 2014; Legro et al., 2014; GoodRx, 2022).


Figure 1: Fertility pills versus injections. Source: Shecares.com.

The high cost of fertility treatments has created a system that actively discourages people with low financial power from being able to “afford parenthood” if they experience infertility. In the United States, women earn significantly less than men, creating a class gap between men and women such that women are more likely to be poor than men. There is also systemic racism which negatively impacts African Americans/Blacks’ educational attainment, career growth, and earning power. This means that African Americans/Blacks continue to make up a disproportionate percentage of the poor population. This combined economic effect of sexism and racism explains why African American/Black women are disproportionately poor compared to other demographics and less likely to afford out-of-pocket costs of fertility treatments. It has been established that African American/Black women are more likely to be under or uninsured compared to White women, thanks to systemic racism and a higher rate of poverty. Like other public insurance programs, the Medicaid program – which provides health insurance for low-income people – does not provide coverage for fertility treatments. In most states, private insurers are not mandated to provide fertility treatment coverage. In some cases, insurance plans cover only certain aspects of fertility treatment, leaving the patient to pay what is left (Weigel et al., 2020).

African American/Black women generally experience healthcare differently from White women because of their class and race despite the common gender location (Valdez & Deomampo, 2019). This fragmented healthcare system, where access to fertility treatment is not mandated in all states, further worsens the disparity in access to fertility treatments. Thus, racism and classism continue to determine which woman has access to fertility treatments and other assisted reproductive technologies, what treatment they have access to, and the outcome (Insogna & Ginsburg, 2018).


The fertility marketplace is awash with brokers seeking to make huge profits, so there is an imbalance of power from the onset for an African American/Black woman seeking fertility treatment. Social, political, and economic inequalities in the healthcare industry have created a reproductive hierarchy where access to fertility treatments and assisted reproductive services are available to only a select group of women (Roberts, 2009; Valdez & Deomampo, 2019).

Figure 2: Mandates for Provision of Infertility Benefits in States Across the United States. Weigel et al., (2020) Kaiser Family Foundation.

African American/Black women have higher infertility rates and lower birth rates than White women (Weigel et al., 2020) yet have less access to fertility treatments and assisted reproductive technologies because of the intersection of their gender, racial, and class identities (Roberts, 2009; Kaiser Family Foundation, 2020). While it is true that African American/Black women are less likely to seek fertility treatment, the solution is not as simple as saying that African American/Black women need to be more proactive in seeking assisted reproduction options. There is a racially-motivated cost and access issue that African American/Black women face, which has not been adequately explored and addressed. Yes, African American/Black women with infertility issues should be encouraged to seek fertility treatments and other assisted reproductive services, but access to comprehensive health insurance and reduced out-of-pocket costs will make the most difference. This has been proven to work in the past. In a 2006 study, researchers compared assisted reproduction services utilization for African American and Non-Hispanic White women after reducing cost and equalizing access. At the end of the study, African American women reported a 4-fold increase in the utilization of assisted reproduction services (Feinberg et al., 2006).


Interventions that improve African American/Black women’s self-advocacy skills and help forge trusting patient-provider relationships are needed but insufficient. We need a more targeted approach that recognizes the unique challenges with cost and access faced by African American/Black women for these interventions to succeed (Kaiser Family Foundation, 2020).

 

Editorial Note: This post is part of the Pharmaceutical Inequalities series, funded by the Holtz Center and the Evjue Foundation.

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