Racial Disparities in Infertility Rates and Treatment Access for BIPOC Women

Danielle Moylan sat waiting at a small clinic in Istanbul, eyeing the vast range of color that decorated the walls—three different shades of cream—when her doctor broke the news that her fourth I.V.F. attempt failed. Moylan’s smile faded, her hope shattered as she reflected on everything she had tried: two types of reproductive medication, timed sex, two surgeries, and three rounds of I.V.F. that she flew to Istanbul for, just so she could afford the treatment. 

Originally from Afghanistan and now a journalist for The New York Times, Moylan is not alone; there is an active reproductive disparity between BIPOC women and their white counterparts. There has been several decades of research substantiating the disparity in maternal and infant mortality rates, in particular for Black women in the U.S., regardless of socioeconomic status (Stanford Institute for Economic Policy Research, 2022). For example, UW Medicine Newsroom from October 28, 2019, unveils a shocking statistic, “college-educated black women are five times more likely to die from pregnancy-related complications than their white counterparts.” This growing body of research illustrates a painful disparity in reproductive care—that BIPOC women struggle to keep their babies (Jang & Lee, 2022), after working so hard to nurture them. When the Centers for Disease Control and Prevention, last accessed March 13, 2024, spotlights that African American women have 2.4 times the infant mortality rate as white women, and African American infants are almost four times as likely to die from low birth weight complications as compared to white infants, it becomes clear that the focus on maternal and infant health outcomes in reproductive care research has been crucial. However, glaring disparities BIPOC women face at the other end of the reproductive health spectrum have only recently come to light: higher infertility rates and lower access to fertility treatment. 

New approaches in developing prenatal reproductive solutions for BIPOC women must address these persistent disparities in maternal outcomes. To move forward in improving the health experiences for these women, a working definition of equitable reproductive care must be established within a reproductive justice framework, one that’s not limited to only socioeconomic differences between white and BIPOC women. This bioethics research paper will overview the problems and causes behind BIPOC infertility struggles, and finally, develop solutions for the best practices toward transforming BIPOC reproductive care—because women like Moylan shouldn’t have to feel emotionally and financially blocked from something so seemingly simple: watching their own babies blossom. 

BIPOC women face higher levels of infertility compared to their white counterparts. The American Psychological Association, last accessed March 8, 2024, spotlights, “Black, Asian, and Latina women undergoing fertility treatment experience decreased pregnancy and live birth rates in comparison to White women,” and CBS News from September 28, 2022 continues, “Black women are twice as likely as white women to experience infertility.” This research underscores that BIPOC women are less likely to encounter successful treatment, even after overcoming barriers to accessing healthcare in the first place. Black women in the U.S. experience these disparities in both infertility and treatment access at disproportionate rates, and for different, more nuanced reasons. The Guardian from December 10, 2023 unveils, “Black women in particular, contending with discriminatory reproductive care and saddled with the trope of hyper-fertility, face a more difficult issue: they need assisted reproductive technology (ART) and other medical interventions at a much higher rate than they’re receiving them.” What this illustrates is that, along the entire reproductive health continuum—not just in terms of birth outcomes—BIPOC women are facing barriers to adequate treatment or care. In fact, the aforementioned article from The Guardian emphasizes, “Black women are half as likely as white women to seek help for infertility.” In one clinical database review of 80,390 ART cycles—defined as any fertility treatments handling eggs or embryos—white women were involved in 85.4% of them, yet only 4.6% involved Black women. Considering that a 2023 U.S. Census report highlights Black women as 7.7% of the total U.S. population and 15.3% of the U.S. population of women, it becomes clear that there is an active disparity in access to fertility treatment. 

From this disparity, Black women receive the message that their health will never come first, and that struggle or pain are mandatory parts of a Black woman’s journey to become a mother. When public health policies only target economic drivers of maternal and infant health disparities, communities are unable to see the reality— that white mothers, despite their income level, have an inherent advantage compared to any Black woman. BIPOC women should not have to feel completely shut out from receiving proactive reproductive care like their white counterparts can, all stemming from what The Bump from January 9, 2024, calls, “pervasive stereotypes about the Black body and Black sexuality, which have wound their way into not only the medical industry, but also individual thinking.” It’s now been well reported that disparities in reproductive healthcare for Black women have existed for decades (Sutton, et al., 2021), but the discourse surrounding reproductive health justice for BIPOC women is hardly shifting in the direction that it should. We need to make these women and their future babies an active priority. Without newer, nuanced information and care, we continue to gloss over the reproductive needs for these women, further perpetuating their heartbreak.

Physiological Health Barriers, Obstetric Racism, and a Lack of Affordable Care

Vinnia McCoy finally got pregnant after only being married once, for a decade. She was ecstatic, but after a few months, she lost her baby to fibroids. She moved from the north-east to North Carolina to try an in vitro fertilization (IVF) treatment cycle there. McCoy only had four embryos, and to maximize her chances, the medical specialists placed all of them inside of her at once. She only came out with one baby, but McCoy considers herself lucky; many Black women with fibroids come out with none. McCoy’s story highlights three major causes of disparities in reproductive care for BIPOC women: fibroids and physiological health barriers, intergenerational trauma bleeding through decades of obstetric racism, and a lack of affordable care. 

First, physiological health can dictate infertility trajectories for BIPOC women. CBS News from September 28, 2022, underscores that one reason for the higher infertility rates faced by Black women is fibroids—often problematic, abnormal uterine growths—and 80% of African American women have them. The scientific community still doesn’t know exactly why Black women face fibroids at disproportionately higher rates than white women, especially when federal funding is limited towards this cause. A lack of Black researchers and physicians have left a gap in clinical research. However, there is a correlation published in previous clinical studies between chronic stress or racial bias and Black women with fibroids, who experience them much earlier than white women, and have more painful symptoms, like heavy bleeding. Vox from June 15, 2023, furthers, “The fibroid disparity is linked to limited access to skilled gynecological doctors and racial bias in health care, leading to delays in diagnosis and suboptimal treatment by medical professionals.” Black patients’ concerns are frequently dismissed, but it isn’t just their comfort on the line—it’s their lives. 

Second, obstetric racism can perpetuate cycles of intergenerational and racial trauma. Historically, Black women were never afforded the luxuries of privacy or autonomy when it came to their fertility, which has always been regulated by the dominant race or class. Black women’s bodies were first used as replaceable vessels, expected to supply free labor through the children they gave birth to, but this culture abruptly shifted. Society flipped the switch, trying to then weaken or prevent Black women’s assumed hyper-fertility. The Guardian from December 10, 2023, clarifies, “Starting in the early 1900s, 32 states passed eugenics laws…Black, Indigenous, and Latina women were forcibly sterilized in government-funded programs, a practice that continued well into the 1970s in states like North Carolina and Alabama.” The direct impacts of these inhumane practices continued up to only fifty years ago, and this blatant mistreatment from the medical establishment has bled into many Black women’s modern day resistance towards using ART. In fact, BIPOC women are forced to be skeptical about the treatment and care they are receiving; in many instances, Black women face obstetric racism—which is enacted on racialized bodies that have historically experienced subjugation, especially, but not solely, reproductive subjugation (Davis, 2020). BIPOC women frequently worry about how they will be perceived by family members and doctors alike for seeking pregnancy at unconventional ages, and this stress can manifest itself through emotional trauma, depression, and perceived fear of rejection for breaking societal norms. But when their worst fears are confirmed, especially if they experience obstetric racism simply for asking how they can have healthy babies in light of unique obstacles, they are further reinforced to avoid speaking up, at all costs. 

BIPOC women are reluctant to seek OBGYN care due to a legitimate mistrust of a historically prejudiced and predominantly white, upper-class profession seeking to exploit their bodies. HuffPost from January 22, 2024, unveils, “One stereotype that has become more apparent due to the Black maternal mortality crisis is the misconception that Black women have higher pain thresholds.” Not only is this false narrative incredibly harmful, but it has dangerous implications for how health care providers treat Black women, and especially those who express pain-related symptoms. This dismissive treatment can, in turn, fuel many Black women’s distrust of healthcare professionals. NBC News from February 14, 2024, furthers, “Black women’s fear of dying during pregnancy and childbirth is a reflection of real-life risks. The maternal mortality rate of Black women in 2021 was 2.6 times higher than the rate of white women.” These statistics speak for themselves; with Black women constantly in a state of high-stress over racial stereotyping, obstetric racism, and now, mortality, one thing becomes clear: these women have historically gone unheard in heartbreakingly high capacities, and history is still being repeated. 

Dr. Joy Cooper, an OB-GYN and the CEO and co-founder of Culture Care, a telemedicine startup company that connects Black women with Black doctors, stresses on February 14, 2024, “There’s no evidence out there that says a Black, Latina, or Native American person is somehow physiologically genetically at increased risk of C-sections. Yet, race is still embedded as a factor in the calculator.” The fact that BIPOC women even seek out healthcare at all, in light of this jarring research, is a testament to their bravery, and their willingness to above all, do right by their future babies. Unfortunately, even once these women do overcome any possible distrust of medical professionals and seek care, they face prominent, pervasive bias in the reproductive health care profession. The New York Times from December 12, 2023, clarifies, “Analyses of taped conversations between physicians and patients found that doctors dominate the conversation more with Black patients. In medical notes, doctors are more likely to express skepticism about the symptoms Black patients report.” These reported studies underscore the cognitive bias and prejudice BIPOC women, and especially Black patients, are faced with when seeking medical care. For a subject as vulnerable and private as reproductive health, BIPOC women should have the floor to detail their symptoms to physicians. But when they’re pushed out of the room faster than white patients, given less time to ask questions, and automatically assigned labels like “aggressive” or “emotional,” they face higher levels of fertility mistreatment, both intentionally and otherwise. 

Finally, a lack of access to affordable care can hinder BIPOC women in starting families. The Guardian from December 10, 2023, explains that our social narratives about infertility have been centered on white, upper socioeconomic-class couples. By focusing on high-tech, highly-expensive medical interventions like IVF, our society became responsible for “the dichotomy between perceptions of women of color who have too many babies and white women whose ability to have babies is viewed as something we need to support.” When considering financial barriers to standardized fertility treatments like IVF, we must also shine light on disparities between Black and white women in regards to health insurance specifics. IVF cycles can, on average, cost around $15,000 to $20,000. Luckily, some insurance companies are starting to include IVF or some form of fertility treatment in their coverage options. According to the National Infertility Association, “As of September 2023, 21 states plus DC have passed fertility insurance coverage laws, 15 of those laws include IVF coverage.” However, Black and Hispanic women are not only uninsured at higher rates than their white counterparts (Hill et al., 2024), leading to blockades in access to these forms of coverage, but they are more likely, when insured, to have public insurance like Medicaid, compared to the private insurance forms that their white counterparts have. This would ultimately serve as a financial block to these recent coverage laws. According to CBS News from February 22, 2024, “Only two states’ Medicaid programs provide any fertility treatment: New York covers some oral ovulation-enhancing medications, and Illinois covers costs for fertility preservation.” This lack of fertility treatment coverage by Medicaid in 48 other states illustrates a deep rooted issue for any families falling in lower income brackets, but especially BIPOC women. Paying such steep prices, especially for multiple rounds of IVF when the first few rounds are frequently unsuccessful, can seem like an incredibly daunting task, on top of the emotional burden of feeling incomplete or unworthy of becoming a mother, and having to seek out help in the first place.

Novel Reproductive Approach Centering Future Success for BIPOC Women

When Sage Howard hit her thirties, her most frequently asked question was what her plans were for having more kids. Each time she experienced one of these countless conversations with her loved ones, her heart skipped a beat, and the same lingering fear popped into the back of her mind: It’s too late. Howard had never felt like egg freezing was within reach for her as a Black woman; None of her close friends had ever openly discussed the idea of getting tested to find their egg counts, and most of them weren’t aware that it was an option. Howard had passively considered how expensive it probably would be, but her primary concern was something else entirely—it didn’t feel culturally or racially appropriate to her. Without access to information about her options for fertility treatment, Howard didn’t allow herself to fantasize about the future she so desperately wanted: to make a family. 

Assisted reproductive technology (ART), as previously mentioned, is defined as any fertility treatments handling eggs or embryos, and includes a variety of methods, with the most common procedures being IVF, cryopreservation of embryos, and cytoplasmic transfer (CD). In I.V.F., the fertilization of an egg by sperm takes place in a laboratory setting (Aznar & Tudela, 2020). Alternatively, cryopreservation consists of the freezing of eggs or embryos, while cytoplasmic transfer is a procedure where the cytoplasm is removed from from a donor egg—often younger—and injected into an egg with compromised mitochondrial DNA, which can lead to diseases in the baby if left untreated. Prior discourse in the field of reproductive bioethics has frequently considered ethical issues involving IVF, cryopreservation, or CD treatments. These issues include but are not limited to the loss of embryos that can occur in IVF, the embryo selection carried out using preimplantation genetic diagnosis to transfer high quality embryos, and the use of ART techniques for social purposes, like ‘social egg freezing’ or ‘gestational surrogacy’ (Aznar & Tudela, 2020). Although these futuristic concerns make for interesting and intellectual discourse, this paper argues that the forefront of our modern bioethics concerns should center tangible solutions for BIPOC women to receive consistent, standardized care that is simultaneously equitable. 

To address obstetric racism, multiple Chicago-based efforts are making waves for BIPOC women. The University of Illinois College of Medicine and The Center for Research of Women and Gender are currently expanding a research and community care project titled, “Melanated Group Midwifery Care,” (MGMC). MGMC is a novel model of maternal health delivery that incorporates strategies that improve maternal health care experiences for Black mothers including but not limited to racial concordance matching Black patients to Black midwives to bolster patient satisfaction, group prenatal care to improve social support, nurse navigation support to connect patients with referrals and specialty care, and postpartum doula support to alleviate postpartum depression. MGMC offers a unique intersection of emotional and social support for BIPOC mothers; with someone to hold their hand and lean on throughout the pregnancy, infertility, or postpartum processes, BIPOC mothers can focus on their health and helping their babies blossom, without facing barriers like obstetric racism or increased risk factors for physiological health barriers. By mirroring these efforts across the nation, either through medical schools or community-based campaign efforts with non-profit organizations, community efforts can help BIPOC mothers have a higher quality of reproductive health care, ultimately furthering the cause of eliminating higher risks of infertility. 

While we continue to advocate for medical insurance coverage that includes fertility treatments, we should simultaneously push for healthcare professionals to bring up the topic of reproductive health with clients, even if they work in other fields, and encourage clients to discuss early reproductive options with their health care providers. This way, BIPOC women will have an opportunity to receive referrals to fertility experts, and feel supported at each step of their respective journeys. Clinical research has emphasized that BIPOC mothers can feel hopeless after disparate fertility treatment outcomes (Weiss & Marsh et al., 2023), and compared to White women, Black women were five times more likely to have self-referred and Hispanic women were four times as likely to have been referred to a clinic by a friend or family member (Missmer et al., 2011). Solvency for this disparity in comfort levels toward seeking treatment can range from racial concordance between patient and provider, to a simple sharing of information, resources, and referrals through virtual, independent networks—which can help BIPOC women feel supported through each of their treatment concerns and allow them to ask questions with women their age or background on preferences for shots or egg freezing. These networks also help women gain access to financial resources, like donations to GoFundMe pages to help assist with the high prices of I.V.F., or even travel to clinics with suitable treatment; ultimately, even one small step taken towards boosting a BIPOC woman’s comfort on their journey to motherhood is a significant, worthwhile step taken towards promoting diversity and inclusion in our next generation’s communities. 

By continuing to advocate for equitable practices in modern reproductive health care, health care providers, especially BIPOC professionals in these fields, can work to eliminate this disparity in referral rates, and ultimately increase BIPOC women’s access to infertility treatment information, options, and care. The Journal of Obstetrics and Gynecology from October 2023 explains, “The theoretical lens through which these disparities are viewed has existed for decades and is the product of Black female scholars who reclaimed female reproductive autonomy with the creation of the Reproductive Justice framework.”

Planting the Seeds for a Future Reproductive Framework

Solutions at the individual and local levels are incredibly worthwhile, as they have the potential to create immense, positive change in the lives of BIPOC women. However, when considering the large-scale benefits of amplifying BIPOC women’s voices, sharing information, and committing to fruitful advocacy, it becomes crucial to strive for federal change. BIPOC women deserve to reach higher levels of fulfillment in their reproductive care experiences; fulfillment that they have missed out on for countless generations. One way to promote federal change towards this cause is to pass legislation to address chronic reproductive healthcare issues; in fact, in recent years, Black women in professional fields have been making strides in advocating for legislative policy shifts towards reproductive injustices. “The Black Reproductive Justice Policy Agenda,” co-authored by over thirty Black-led organizations committed to improving health outcomes for Black women, has detailed comprehensive plans and policy shifts to help make strides in progress towards addressing the disparities in reproductive health outcomes for Black women in particular. For example, as continued by organizers for the framework, “Legislation like the Stephanie Tubbs Jones Uterine Fibroid Research and Education Act would increase patient and provider education about Black women’s uterine risk for fibroids. It would establish new funding for NIH…and develop comprehensive fibroid information for health care providers.” Not only does the Black Reproductive Justice Policy Agenda guide expand on countless policy shifts like these through informative subheadings and bullet points, but even overviews history, current disparities, and modern solutions to the maternal health crisis. Guides like these not only include Black female professionals in the conversation, but actively center their voices, encouraging them to spearhead future efforts. Amplifying Black female voices, alongside their nuanced perspectives, is the most effective method to end this public and maternal health crisis for BIPOC women. 

By continuing to promote the reproductive justice framework, especially through sharing, posting, and advocating for handbooks like the Black Reproductive Justice Policy Agenda, we can incorporate next steps for future BIPOC babies and mothers to have increased access to equitable reproductive care at every stage of their journey, ultimately promoting reparations that are both equitable and compassionate. Danielle Moylan, Vinnia McCoy, and Sage Howard all shared the same initial feeling of defeat when exploring their reproductive options, forced to wonder if they even had any at all. Barriers to securing reproductive care have persisted through generations for these women, meaning that they aren’t the first in their struggles, nor will they be the last. However, by continuing to push for a novel approach that eliminates BIPOC infertility disparities through justice frameworks, we can help future mothers plant the seeds for their reproductive journeys to flourish—in full bloom.