Removing the Barriers to Infertility Care

While the decision to get pregnant and have a child is a decision that is often carefully thought over, for some that option is taken away. Infertility affects millions of people of reproductive age, with some estimates suggesting that between 48 million couples and 186 million individuals are affected globally (WHO). The causes for this condition vary, with most being traced back to abnormalities in sperm, the ovaries, uterus, fallopian tubes, and the endocrine system.

However, there are a variety of options for those looking for treatment. These treatments can depend on multiple factors, including the cause, how long an individual has been infertile, age, as well as personal preferences. One treatment is the use of assisted reproductive technology, with the most common technique being in vitro fertilization (IVF). IVF involves “stimulating and retrieving multiple mature eggs, fertilizing them with sperm in a dish in a lab, and implanting the embryos in the uterus several days after fertilization” (Mayo Clinic). Other options include artificial insemination, in which sperm is transferred directly into someone’s uterus, and ovulation induction, where hormone medication is used to stimulate the ovaries to produce multiple mature follicles and ova.

Despite these different options for infertility care, limited information, high costs, and stigma, put this care out of reach for many, especially those in marginalized communities. One of the greatest obstacles to obtaining infertility care is the high out-of-pocket cost. Combined with the limited number of private insurance and public programs that covers infertility services, this economic barrier denies many the opportunity for infertility treatment. In fact, the median cost of a single IVF cycle in the United States is $19,200 (WHO). This hefty price tag is one that only those of high economic standing can afford, with one study finding that women without insurance coverage were three-times more likely to discontinue treatment after their first cycle because of the high price (Bronwyn Bedrick et al.).

Racial disparities in access to infertiliy care is well-documented within the United States. For example, while black women of reproductive age are 80% more likely to report they’re infertile compared to white women, they are actually 20% less likely to receive infertility care (Ada C. Dieke et al.). Furthermore, Hispanic and American Indian/Alaska Native non-Hispanic women have shown below average rates of infertility care use (Ada C. Dieke et al.). Part of the reason for these disparities could be the way IVF and other infertility care is marketed. As most people believe that IVF is something only the rich and white do, minorities are less likely to seek out these treatments. However, the root of the problem lies in our healthcare system: the high costs of care and lack of insurance coverage.

These barriers don’t have to exist. With better information given to the general public, more people can learn about the options they have for infertility care. More importantly, at the very least, we need to fight to have infertility care covered by insurance. Removing these drastic economic barriers will allow more people to gain access to this vital treatment. Being able to have a child is a basic human right and it’s the responsibility of those involved in reproductive and fertility care, including physicians and policymakers, to be aware of and address these barriers.

Edited by: Nana Osaki

Graphic Designed by: Alejandra Gonzalez-Acosta

References

1. https://reproductiverights.org/wp-content/uploads/2020/02/64785006_Infertility-and-IVF-Access-in-the-U.S.-Fact-Sheet_2.5.2020_Final.pdf

2. https://www.who.int/news-room/fact-sheets/detail/infertility

3. https://www.mayoclinic.org/diseases-conditions/infertility/diagnosis-treatment/drc-20354322

4. Bronwyn Bedrick et al., Factors Associated with Early In Vitro Fertilization Treatment Discontinuation (July 2019), 112 FERTILITY & STERILITY 105 (July 2019), https://www.fertstert. org/article/S0015-0282(19)30250-X/fulltext.

5. Ada C. Dieke et al., Disparities in Assisted Reproductive Technology Utilization by Race and Ethnicity, United States, 2014: A Commentary, 26 J. WOMEN’S HEALTH 605 (2017), https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5548290/ (hereinafter Dieke, Disparities)

The Injustices Within the Black Maternal Mortality Epidemic

Despite Black Americans making up 13.6% of the U.S. population, the maternal mortality rate for non-Hispanic/Latina Black women in 2020 was 55.3 deaths per 100,000 live births—almost three times more than that for non-Hispanic/Latina White women [1]. Unfortunately, during the COVID-19 pandemic, the Black maternal mortality rate increased to 68.9 deaths per 100,000 live births in 2021, a much larger mortality rate increase than for non-Hispanic/Latina White women [2]. As a Black woman who wants to have children someday, these statistics terrify me, and I believe that we should not be complacent in accepting this disproportionate mortality rate as the norm. More needs to be done to address the social determinants of health that lead to racial disparities in maternal healthcare, and more needs to be done to protect Black mothers.

Researchers have found that disparities such as lack of access to care, poor health insurance coverage, socioeconomic inequalities, racism, discrimination, and chronic stress contribute to worsening maternal health outcomes [3]. Health insurance coverage before and throughout pregnancy allows mothers to have better access to prenatal care, which includes physical exams, discussions on the health of the mother and the fetus, weight checks, breast checks, and blood tests [3, 4]. Access to this care is essential in reducing the risk of pregnancy complications, but people of color, specifically Black Americans, experience differences in health insurance coverage and more barriers to healthcare, especially in rural populations that are typically medically underserved [3]. The structure and finance of the U.S. healthcare system have been shaped by racial discrimination since the Jim Crow era (1875-1968) [5]. For instance, when the Hospital Survey and Construction Act was passed in 1946, states were allowed to build healthcare facilities that were racially separate and unequal. Additionally, federal programs to provide care to the poor were not supported by many state governments, and even today, inequalities under the Affordable Care Act exist in insurance coverage, financing care, and quality of care [5].

Concerning mortality rates, the leading causes of maternal death for Black women were the gestational high blood pressure disorders pre-eclampsia and eclampsia and a form of heart failure called postpartum cardiomyopathy. Black women were five times more likely than White women to die from these illnesses, and they were also two times more likely to die of severe bleeding or blood vessel blockages during and after pregnancy [6]. Therefore, frequent access to adequate care and better health insurance coverage is necessary to bridge the gap of the disparities that burden and kill pregnant Black women in our country.

Though a lack of access to adequate healthcare negatively contributes to poor maternal health, the combination of socioeconomic inequalities, systemic and structural racism, and discrimination against Black mothers are reported to be the primary factors of poor maternal health outcomes [3]. A survey on race and health that was conducted in 2020 and included over 800 Black participants found that most Black adults felt that the American healthcare system discriminates against people according to their race; this same survey reported that 37% of Black mothers were mistreated due to their race when receiving healthcare for themselves or a relative [7].

Other inequalities, especially those exacerbated by the COVID-19 pandemic, have disproportionately affected the Black community and Black mothers. For example, it is widely known that poverty disproportionately affects communities of color, especially with affordable housing, public transportation, access to healthy food, and quality of education. Research has shown that the chronic stress associated with this poverty has contributed to racial maternal health disparities [8]. Overall, these inequalities contribute to the problems we are seeing in Black maternal healthcare and show that America, specifically the U.S. healthcare system, needs to do better in providing care and listening to Black women.

One way that Black maternal health outcomes can be improved is through more government support in increasing access to maternal healthcare. In June 2022, the Biden Administration published the Blueprint for Addressing the Maternal Health Crisis. This document describes how federal agencies need to prioritize increased health insurance coverage, data collection and research, a larger and more diverse prenatal workforce, and other incentives to improve maternal health [3]. Additionally, the Health Resources and Services Administration has allotted over $300 million for states to strengthen maternal and infant health, and the Office of the Assistant Secretary for Health has invested over $8 million into initiatives to reduce maternal deaths and health complications that hurt people of color and people living in rural areas [3].

Only time will tell if these initiatives can decrease the overall maternal mortality rate and decrease the number of Black women who die every year due to pregnancy-related issues. The maternal mortality rate being three times higher for Black women than it is for White women should not be viewed as just another statistic or number on a piece of paper. This epidemic is scary, preventable, and unacceptable, and it highlights the injustice that Black women constantly face in healthcare settings. I am tired of seeing this disparity grow bigger and bigger every year, and I hope that one day, I will live in a country where I do not have to worry about Black women being pushed aside, disregarded, and ignored by our healthcare system.

Edited by: Sanjana Anand

Graphic Designed by: Natalie Chou

References

1. Hoyert, D. L. (2022, February 23). Maternal mortality rates in the United States, 2020. Centers for Disease Control and Prevention. Retrieved March 3, 2023, from https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm#Suggested_citation

2. United States Government Accountability Office. (2022, October). Maternal health: Outcomes worsened and disparities persisted during the pandemic. GAO Report to Congressional Addressees. Retrieved March 4, 2023, from https://www.gao.gov/assets/gao-23-105871.pdf

3. Hill, L., Artiga, S., & Ranji, U. (2022, November 1). Racial disparities in maternal and infant health: Current status and efforts to address them. KFF. Retrieved March 3, 2023, from https://www.kff.org/racial-equity-and-health-policy/issue-brief/racial-disparities-in-maternal-and-infant-health-current-status-and-efforts-to-address-them/#:~:text=Research%20has%20documented%20that%20social,of%20mortality%20among%20Black%20infants

4. National Institutes of Health. (2017, January 31). What is prenatal care and why is it important? Eunice Kennedy Shriver National Institute of Child Health and Human Development. Retrieved March 3, 2023, from https://www.nichd.nih.gov/health/topics/pregnancy/conditioninfo/prenatal-care#:~:text=Prenatal%20visits%20to%20a%20health,tests%2C%20such%20as%20ultrasound%20exams

5. Yearby, R., Clark, B., & Figueroa, J. F. (2022). Structural racism in historical and modern US health care policy. Health Affairs, 41(2), 187–194. https://doi.org/10.1377/hlthaff.2021.01466

6. PRB. (2021, December 6). Black women over three times more likely to die in pregnancy, postpartum than white women, new research finds. PRB.org. Retrieved March 3, 2023, from https://www.prb.org/resources/black-women-over-three-times-more-likely-to-die-in-pregnancy-postpartum-than-white-women-new-research-finds/

7. Hamel, L., Lopes, L., Muñana, C., Artiga, S., & Brodie, M. (2020, October 13). KFF/The undefeated survey on race and health. KFF. Retrieved March 3, 2023, from https://www.kff.org/racial-equity-and-health-policy/report/kff-the-undefeated-survey-on-race-and-health/

8. National Partnership for Women & Families. (2018, April). Black women's maternal health: A multifaceted approach to addressing persistent and dire health disparities. National Partnership for Women & Families. Retrieved March 3, 2023, from https://www.nationalpartnership.org/our-work/health/reports/black-womens-maternal-health.html

Not Just Postpartum Depression: Breaking Down Barriers to Perinatal Mental Health Care

It is estimated that 1 in 7 birthing people will develop postpartum depression (PPD). While recognizing and treating PPD is important in perinatal mental health care, it isn’t the only diagnosis that needs to be addressed. There are many conditions that may affect people during and around pregnancy including depression, anxiety disorders, and psychosis. In recent years, discussions around PPD have become more common, but major barriers still exist for pregnant people seeking mental health care. To address these barriers, we must reduce the stigma, adequately train providers, and make mental health care more accessible.

On the patient side, it’s important to address and mitigate the stigma that exists around mental health, specifically during pregnancy. The common narrative in our culture holds that pregnancy should be the best time of a person’s life. As a result, anyone struggling may feel as if they are alone, which often prevents them from seeking help. For those being medically treated for psychiatric conditions prior to pregnancy, there are often social pressures to stop these medications for the sake of their future child. The American Medial Association recognizes this as a significant ethical and clinical dilemma, but that dilemma spreads into social spheres as well. Many expecting parents and those around them overestimate the teratenogenic risk associated with medical treatment of psychiatric disorders. Unclear social beliefs and advice can lead to people feeling even more isolated during the conception process and pregnancy itself.

From the provider perspective, there needs to be more education on treating mental health conditions during pregnancy. As of 2022, there were only 15 perinatal psychiatry fellowships in the US to provide formal training for psychiatrists looking to specialize in this patient population. That said, having a baseline understanding of recognizing and treating mental health conditions during pregnancy is needed for all providers caring for pregnant people. We often talk about the fetal risks of exposure to psychiatric medications, but research shows that this risk ought to be balanced with the risks of exposure to untreated psychiatric conditions themselves. Those who abruptly halt treatment are less likely to receive proper prenatal care, more likely to use tobacco and alcohol, and are at higher risk for causing harm to themselves and their child. With the stigma that already exists around psychiatric medications during pregnancy, it is even more important for providers to stay informed of current treatment recommendations and provide this information to their patients.

As we work to decrease the stigma and enhance provider education, it is also important to make sure that mental health care is accessible. This may look like increasing the number of providers, mitigating cost barriers, or making sure that care environments are affirming to all patients. It is currently estimated that roughly 160 million Americans live in mental health professional shortage areas. Psychiatry as a field is expected to have shortages of between 14,000 and 30,000 psychiatrists by 2025, and these shortages spread into other mental health professions as well. Financially, many people cannot afford to pay for mental health care out-of-pocket, and even those with insurance coverage may have difficulty finding providers that take their insurance. As always, the language that we use is important. Replacing phrases like “pregnant women” and “moms” with “pregnant people” and “parents” can go a long way toward making these spaces more affirming for anyone seeking care. Culturally competent care is especially important in mental health. Recent endeavors like the Perinatal Mental Health Alliance for People of Color have worked to address these issues by increasing patients’ access to care and supporting providers of color looking to expand their knowledge of perinatal mental health. Though this program and others like it have worked to close the gap between pregnant people and providers of color, there is more to be done to ensure that all patients can receive culturally appropriate and affirming care.

With 1 in 5 pregnant people likely to need mental health support during the course of their pregnancy, mental health conditions represent the most common complication of pregnancy. The medical community has an ethical duty to provide care to these individuals, but it doesn’t start or end there. We, in the general public, have a responsibility to decrease the stigma around mental health, specifically during pregnancy.

Talk to the people around you, listen to them, and help them find support if you can. The conversation starts with us and can start today.

If you or someone you know is in crisis, please see the resources below:

• National Maternal Mental Health Hotline:

  • https://mchb.hrsa.gov/national-maternal-mental-health-hotline

  • Call or text: 1-833-943-5746

• 988 Suicide & Crisis Lifelines:

  • Call or text: 988

Edited by: Elissa Gorman

Graphic Designed by: Olivia Fu