As soon as puberty hits—commonly around the middle-school years—a lot of what folks learn about pregnancy is almost exclusively about preventing it, and many spend the next few decades of their lives doing everything they can to avoid getting pregnant. Then, ironically—cruelly, even—when the time is finally “right” (although I’m told no one is ever truly ready, and the “right” time is almost never when you expect it), people find out that there may be challenges trying to conceive naturally, especially on the other side of age 35.
While infertility in later childbearing years is a challenging ordeal for any woman seeking to have children, it can be particularly overwhelming for Black women, especially in light of recent events. The nation is in the midst of a Black maternal health crisis, which has only been made worse by the fall of Roe v. Wade. This commentary will provide background on the challenges faced by Black women who struggle with infertility, how the fall of Roe may impact those who use assisted reproductive technology (ART) to become pregnant, and how policy can be crafted to course-correct a failing maternal health care system.
The Intersections of Infertility
The immense challenge that infertility places on Black women striving to become mothers cannot be understood without the historical context of this country’s selective valuation of Black women’s reproduction. Simply put, Black women’s fertility and childbearing has not been valued equally to that of white women. This fact is evident in a range of practices and policies, stemming from the mistreatment of enslaved Black women and continuing in the selectively valued reproduction (or stratified reproduction) of today’s society. From social stigma to cost prohibitive procedures to discriminatory laws and policies, Black women are left to navigate this struggle without many of the supports that white women benefit from. As a result, the interplay of systems of oppression faced by Black women has led to an increased sense of mistrust of the U.S. health care system. This lived experience by Black women is a kind of intergenerational trauma that is woven throughout the Black community and has created a nearly impenetrable barrier to receiving comprehensive, high-quality reproductive health care.
Difficulty getting pregnant is actually not uncommon, among women of all races during their childbearing years. The Centers for Disease Control and Prevention (CDC) reports that approximately 12 percent of women of reproductive age have difficulty getting pregnant or carrying a pregnancy to term. Notably, Black women are nearly two times more likely than their white counterparts to have fertility challenges, but only half as likely to receive treatment. Just last month, a study was published showing that among U.S. women who had undergone various infertility treatments (such as fertility drugs, artificial insemination, or in vitro fertilization/IVF), Black women were three times more likely than their white counterparts to lose the pregnancy soon before or after birth. This statistic is eerily similar to that for the Black maternal mortality rate, which is also roughly three times higher than that of white women. These tragic disparities reinforce what we know to be true of the Black maternal mortality crisis: education level and socioeconomic status are not protective factors for pregnant Black people. In fact, the CDC reports that the pregnancy-related mortality ratio among Black women with a completed college education or higher was 1.6 times that of white women with less than a high school diploma.
Notably, Black women are nearly two times more likely than their white counterparts to have fertility challenges, but only half as likely to receive treatment.
We know that external stressors such as racism, social stereotypes, and financial burden play a significant role in the ability to carry and sustain a pregnancy to term. For Black women trying to become pregnant, they must also consider other contributing factors, such as reproductive health issues that disproportionately impact Black women. Polycystic ovarian syndrome (PCOS), endometriosis, and uterine fibroids all share the common symptom of infertility and increase the likelihood of needing the intervention of ART to achieve a healthy pregnancy.
The Uncertain Future of ART
This summer’s devastating Supreme Court decision in Dobbs v. Jackson Women’s Health Organization that overturned Roe v. Wade has created yet another obstacle to care on the path to parenthood for many families in this country. As outlined above, access to family building supports such as IVF and other ART medicine is difficult and even out of reach for many Black women and families. On top of the uncertainty that looms over the whole process of IVF, patients and providers now have the added burden of navigating the legal minefield left in Roe’s wake. Because the process of IVF involves the creation and/or disposal of embryos, harmful legislation such as “personhood” bills (which proclaim a “right” to life for an embryo from the moment of conception) spurred by the fall of Roe could potentially affect IVF patients and their resulting embryos. This means that patients’ decisions about their embryos—including freezing, thawing, genetic testing, transfer, and storage—are in jeopardy, and criminal liability could be imposed on both providers and patients. As it stands, Louisiana is the only state that prohibits the discarding of embryos, meaning IVF patients now must pay to store unused embryos indefinitely. If similar legislation is adopted in other states, and knowing the cost barriers associated with IVF, the additional burden of indefinite storage fees could push or price those who are already struggling to finance their treatment out of the option completely. It is now left up to the states to affirm or deny whether one’s reproductive autonomy and ability to conceive will be sacrificed for the sake of a nonviable embryo.
The future of IVF is uncertain, in part because ART has only been around since the 1980s, when Roe was considered established precedent. Recent changes in the legal landscape could leave access to fertility care in limbo as each state considers the fate of abortion access, and challenges to restrictions are sorted out in the courts and at the ballot box. At the moment, many women hoping to become mothers may soon see limits to the IVF process through “personhood” bills passed by their state legislators—who feel they know better than their constituents on how and when to build a family—only to have that changed yet again by legal challenges or election outcomes down the road. The impact of the fall of Roe cannot be understated for those with hopes to become pregnant who may need the assistance of reproductive medicine. With this loss of bodily autonomy, the threat to Black maternal health has never been more dire.
The overlap of health crises for Black women has only been exacerbated by the ongoing COVID-19 pandemic. Just last month, the Government Accountability Office (GAO) published a report on the impact that COVID-19 has had on maternal mortality and morbidity over the past two years. The findings suggest that COVID-19 contributed to 25 percent of the 2,000 maternal deaths between 2020 and 2021. Furthermore, Black women experienced 68.9 deaths per 100,000 live births, as compared to 27.5 maternal deaths per 100,000 live births among white women. The Department of Health and Human Services (HHS) and key stakeholders determined that COVID-19’s impact on inequities in the social determinants of health—such as the ability to access care, employment, transportation, and living environment—as well as racism were responsible for worsening maternal health outcomes. Maternal health and infant mortality are among the strongest indicators of our nation’s overall health and well-being. These numbers are beyond alarming and highlight the disparate impact faced by Black women at the hands of structural and systemic racism.
Black women experienced 68.9 deaths per 100,000 live births, as compared to 27.5 maternal deaths per 100,000 live births among white women.
To recap, Black women experience disparate outcomes in maternal mortality and infant mortality (even higher when ART is used), as well as disproportionate rates of reproductive health issues that contribute to infertility. Understandably, these compounding crises can take a toll on the mental health of those seeking to grow their families. Now more than ever it is critical to make meaningful investments to improve maternal mental health and ensure that Black women have the support they need to care for themselves and their family.
Our Health Care System Is Failing Black Women—Here’s What Needs To Be Done
As a Black millennial woman working in the health policy field who has yet to embark on the family building process myself, I am acutely aware of just how difficult it is to navigate this journey and where the obstacles lie. Increased access to IVF and other ART treatments cannot mitigate the impact of structural racism; however, there are policies and practices that can be implemented to address the root cause—which is racism—of the disparities we see in both maternal and infant health outcomes, regardless of how a pregnancy is achieved.
It is important to acknowledge that infertility does not exist in a silo. An individual can experience challenges becoming pregnant and need access to fertility care, be pregnant and need access to abortion care, be pregnant and need access to respectful maternal health care, and suffer a pregnancy loss and need access to prenatal, birth, and postpartum care. Recognizing this, the following policy solutions promote equitable access to the full spectrum of sexual and reproductive health care:
- Ensure equitable access to primary health care services by expanding Medicaid nationwide, and implementing permanent nationwide Medicaid postpartum extension from sixty days to one full year. As of 2022, forty states and the District of Columbia have adopted the Medicaid expansion. The holdout twelve states are mostly concentrated in the South, leaving millions of people without health insurance. Although many states have extended Medicaid postpartum coverage to a full year, health coverage for a year postpartum should be available to every pregnant person in every state. Many of the states that have not opted to extend postpartum coverage are those with the worst maternal health outcomes.
- Enact a national fertility care mandate that requires health plans to provide insurance coverage for infertility diagnosis, treatment (including IUI and IVF), and necessary medication that may be required for treatments. The lack of coverage for these basic fertility services is often an overlooked, costly barrier to care. The mandate should include Medicaid, the Federal Employee Health Benefits (FEHB) program, TRICARE, and the Veterans Health Administration (VA).
- Ensure comprehensive reproductive health care, including abortion, infertility, and maternity care, is accessible and affordable for all. The Women’s Health Protection Act establishes a statutory right for health care professionals to provide abortion care and the right for their patients to receive care, free from medically unnecessary restrictions that single out abortion care. The Equal Access to Abortion Coverage in Health Insurance or EACH Act is legislation to reverse the Hyde Amendment and related abortion coverage restrictions, ensuring that every person who receives care or insurance through the federal government will have coverage for abortion services. Current legislation addressing the maternal health crisis includes the Black Maternal Health Momnibus, which makes robust investments to ensure quality health care and a myriad of social supports that pregnant and postpartum women desperately need. Additionally, there are plans to address unmet needs and support for those who struggle with infertility in the 118th Congress by the newly formed, bipartisan Family Building Caucus.
- Ensure universal paid leave following a birth, abortion, misscarriage, unsuccessful fertility treatment, a failed adoption arrangement, a failed surrogacy arrangement, or a diagnosis that impacts pregnancy or fertility. Current legislation addressing this need include the Universal Paid Family and Medical Leave and the Support Through Loss Act.
- Increase funding for infertility research, including the collection and sharing of data disaggregated by race. This funding stream and subsequent research could be housed by the proposed HHS Office of Sexual and Reproductive Health and Wellbeing, which aims to lead joint interagency planning for the Federal Government’s integrated response to attacks on sexual and reproductive wellness.
With structural and systemic racism continuing to harm Black communities and an ongoing global pandemic whose impact is felt most—yet relief efforts felt least—by Black families, we must address the connections that infertility, maternal health, and abortion restrictions have on the overall health and well-being of Black women and families. Our health care system must be reimagined in order to meet the needs of the most marginalized among us.