This review examines racial and ethnic disparities in reproductive health focusing on 3 key topical areas: (1) infertility, (2) polycystic ovarian syndrome, and (3) reproductive aging. We report that an increasing body of knowledge points toward reduced infertility access and in vitro fertilization outcomes in Asian, black, and Hispanic women compared with white women. There are differences in the reproductive and metabolic phenotypes of Asian, black, and Hispanic women presenting with the polycystic ovarian syndrome compared with white women. Reproductive aging differences appear to exist in all racial and ethnic groups. Awareness of racial and ethnic disparities is critical to a complete understanding of the health issues facing women of reproductive age.
The National Institutes of Health (NIH) defines health disparities as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.” Observed differences in racially diverse populations may reflect true biologic differences because of genetic background or may result from variations in environmental exposures, lifestyle factors, cultural factors, access to care, and specifics of treatments once care has been accessed.
In this article, we review current available information regarding racial and ethnic disparities in 3 selected areas of reproductive health: (1) infertility, (2) polycystic ovary syndrome (PCOS), and (3) reproductive aging. We used an extensive search of PubMed/Medline for all relevant English-language articles utilizing the following subject headings: racial or ethnic disparities and infertility, polycystic ovary syndrome, reproductive aging, or menopause. Additional cross-references were obtained electronically.
Disparities in infertility
Prevalence
Although it is not known whether age-adjusted natural fecundity rates differ between various racial and ethnic groups of women, attention has recently focused on differences in rates of infertility and utilization of infertility services. Evidence suggests black women in the United States have experienced an increasing prevalence of 12-month infertility, whereas a decline has been noted in white women.
Estimates from the National Survey of Family Growth show an increase in self-reported infertility among black married women of reproductive age between ages 15–44 years from 1982–2002 (7.8% in 1982 to 11.6% in 2002). A number of factors influence self-reported rates of infertility, including access to care; percentage of unmarried women in ethnic cohorts; and acceleration of infertility treatment, specifically, assisted reproductive technology (ART).
In addition to having higher rates of infertility, black women presenting for infertility care have a longer duration of infertility compared with white women, suggesting differential access to care based on either economic or sociocultural barriers. In contrast to black women, the proportion of Hispanic women reporting infertility remained relatively stable over the 2 decades (7.2% in 1982 and 7.7% in 2002), despite a dramatic increase in the proportion of married, reproductive-aged Hispanic women in the US population (8.1% in 1982 and 14.6% in 2002).
No data currently exist on the self-reported rates of infertility in the US Asian population. In an analysis of a cohort of women accessing infertility services in Massachusetts, Asian women have higher education and income levels compared with other racial and ethnic groups examined, and infertility treatment utilization is proportionately higher. In contrast, Asian women from the San Francisco Bay area have a longer duration of infertility at consultation compared with white women, suggesting that economic and/or sociocultural factors in this community negatively influence access to care.
Biological and sociocultural differences
An increase in the reporting of positive chlamydial exposure from 78 per 100,000 in 1975 to 485 per 100,000 in 2004 may be a contributing factor to racial/ethnic differences in prevalence of infertility, given the increased proportion of black and Hispanic infertile women presenting with tubal factor infertility. Furthermore, maternal age and other compositional factors not linked to the dataset during multivariate analyses may be important.
Differences in access to care may also have an impact on infertility prevalence and treatment outcomes by leading to decreased treatment of antecedents of infertility (ie, chlamydia) and/or delayed treatment of infertility. Within the United States, fertility treatment is provided by either self-pay or with the assistance of private insurance. Women in lower socioeconomic strata are disadvantaged in their ability to obtain fertility care, a fact that, in general, has a disproportionate impact on black and Hispanic women compared with white women.
Several studies have shown that black and Asian women present with a longer duration of infertility, which may associate with poorer outcomes. Whereas decreased access to care likely plays the most significant role in the low utilization rates of some minority groups, more complicated sociocultural forces may also be relevant, because several studies revealed that black and Hispanic women had reduced utilization of ART services, despite mandated infertility coverage and equal access to care.
Success rates
There is increasing interest in demographic predictors of success with in vitro fertilization (IVF). Emerging evidence demonstrates that women of the 3 major minority groups (black, Asian, and Hispanic) in the US population have reduced live birth rates associated with IVF compared with white women ( Table ) . Furthermore, all 3 groups of minority women were noted to give birth to small-for-gestational-age infants compared with white women. Differences in birthweights between various racial and ethnic cohorts of spontaneously conceived newborns have been shown previously in other studies, suggesting that constitutional and/or pregnancy-related developmental differences may exist independent of IVF effects.
| Race/ethnicity | References | Patients’ designated ethnicity, n | CPR, % a | White reference CPR a | LBR, % a | White reference LBR a |
|---|---|---|---|---|---|---|
| Black | Sharara et al | 37 | 19.1 b | 42.1 | 14.9 b | 38.8 |
| Nichols et al | 24 | 71 | 48 | NA | NA | |
| James et al | 41 | 31.7 | 39.1 | 22 | 29.9 | |
| Bendikson et al | 43 | NA | NA | 20.1 | 18.3 | |
| Feinberg et al | 253 | 39.5 | 42.6 | 29.6 c | 35.8 | |
| Seifer et al (no prior ART) | 1839 | 27.7 b | 33.6 | 20.7 b | 28.4 | |
| Seifer et al (prior ART) | 1277 | 22.1 b | 28.9 | 15.7 b | 23.7 | |
| Dayal et al | 71 | 34 | 28 | 25 | 24 | |
| Fujimoto et al | 8903 cycles d | 32.0 e | 40.1 | 24 b | 33.6 | |
| Asian | Mahmud et al | 44 | 32 | 36.4 | 16 | 30.3 |
| Lashen et al | 108 | 16 | 22.6 | NA | NA | |
| Bendikson et al | 35 | NA | NA | 20 | 18.3 | |
| Purcell et al (clinic-specific) | 197 | 37.1 b | 45.9 | 28.6 b | 37.5 | |
| Purcell et al (SART database) | 1429 | 33.3 b | 41.3 | 26.9 b | 34.9 | |
| Palep-Singh et al (PCOS) | 104 | 31.7 | 39.5 | 26.9 | 33.6 | |
| Palep-Singh et al (tubal factor) | 84 | 33.3 | 33.5 | 25 | 31 | |
| Langen et al | 37 | 35 b | 69 | 32 b | 51 | |
| Fujimoto et al | 13,671 cycles b | 30.9 b | 40.1 | 25.2 b | 33.6 | |
| Hispanic | Bendikson et al | 18 | NA | NA | 16.7 | 18.3 |
| Feinberg et al | 56 | 42.9 | 42.6 | 33.9 | 35.8 | |
| Fujimoto et al | 8969 cycles d | 37.3 e | 40.1 | 30.7 b | 33.6 |
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