Family-building inequities

Systemic disparities can make welcoming a child difficult or even dangerous for certain groups

Here are just a few of the pregnancy and birth-related challenges some populations face — and concrete advice to help payers address these issues on their members’ behalf.

There are few decisions more momentous than the one to become a parent. But for some, this life-changing decision is soon followed by an arduous slog of logistics and scheduling or, far worse, heightened risks around every step.

The individual health risks and heightened financial stakes of family-building in America echo a larger, nationwide crisis in maternal care. Roughly 700 women die each year due to pregnancy or pregnancy-related complications,¹ and many more experience preterm birth, low infant birthweight and other health concerns that can affect themselves or their babies. And as in many aspects of health care, certain populations — such as parents who are LGBTQ+, Black or unmarried — shoulder a disproportionate share of those outsized risks.

Below are 5 sobering statistics about the inequities that make family-building far more difficult and dangerous for certain groups, as well as strategies for payers to strengthen health equity for all.

Lower odds of live birth using IVF for Hispanic (20%) and Black (30%) women

The stat: Though infertility cuts across all racial, geographic and socioeconomic groups — impacting an estimated 10% of American couples — research shows it doesn’t affect all groups equally. For instance, Black and Hispanic women experience significantly higher rates of infertility.² Yet they’re only half as likely as white women to see a doctor for fertility support — a delay rooted, in part, by a complex milieu of financial barriers, systemic bias, cultural norms and coverage concerns.³ When they do seek out medical support, Black and Hispanic women are far less likely to utilize fertility treatments.⁴ IVF rates, for instance, remain highest among white and Asian women and lowest among the very racial and ethnic groups burdened by higher rates of infertility.⁵

The payer strategy: Expanding access for fertility coverage isn’t only a powerful equity play. It also comes with clear business benefits, as closely managing infertility yields both better outcomes and lower costs. Health plans that leverage a highly experienced team of infertility clinicians, adhere to evidence-based clinical guidelines and educate members about optimum treatment options have been able to reduce costs related to infertility treatment and NICU stays by as much as 30% — while helping members build the families they want.

On the flip side, when infertility coverage isn’t available, those trying to conceive often turn to lower-cost procedures that are less clinically exact, raising the risk of multiple births (and the NICU costs associated with such births) by 20%. And when women access IVF later in life, whether through a shift in benefits offerings or finally amassing enough personal financing, that delay in treatment reduces their odds of a positive outcome.⁶ Black women, who start IVF at a more advanced age than white women, on average, also face a dramatically lower odds ratio of a live birth following IVF treatment.⁷ And though that disparity can’t be tied to a lone variable, it’s clear that advanced maternal age elevates the risk of preterm delivery, maternal mortality and maternal morbidity. Expanding the availability of fertility services — to deliver the right treatment at the right time — can help take that compounding risk factor out of the equation.

83% of LGBTQ+ people report childbirth complications

The stat: That more than 8 in 10 LGBTQ+ individuals experience childbirth-related complications is worrisome enough on its own.⁸ But when stacked against the 63% of cisgender, heterosexual parents who report similar complications, the health disparities at play are thrown into stark relief. Many stem, at least in part, from the social determinants of health (SDOH) at play before a member even becomes pregnant: Research shows that LGBTQ+ Americans far more likely to be lower-income, less likely to have attained a college education⁹ and twice as likely to experience homelessness compared with non-LGBTQ+ peers.¹⁰ And though a younger population that one would expect to be in better health, a greater proportion of LGBTQ+ individuals rate their health as fair or poor, with nearly half (47%) managing a chronic health condition or living with a disability that impacts daily life.¹¹

The payer strategy: Partnering with providers and hospital systems to train frontline staff on the particular needs of LGBTQ+ individuals during pregnancy and childbirth — as well as the potential fallout from unchecked bias — is a significant step, as 51% of LGBTQ+ parents felt their medical care had been compromised by bias and discrimination.¹² (Optum, for instance, offers a free and accredited online course on this very subject.) But payers would be wise to also encourage providers to target the underlying SDOH challenges that put this population at elevated risk. That might mean standardizing and implementing SDOH needs assessments as early in the family-building journey as possible, proactively promoting personalized benefits such as transportation to prenatal appointments or smoking-cessation programs, and leveraging data analytics to evaluate and fine tune the tactical elements of that more holistic and comprehensive approach.

50%+ of rural counties have no hospital-based obstetrical care

The stat: Access to maternity care is shrinking in parts of the country that need it most, with 36% of U.S. counties — the majority of them rural — now considered “maternity care deserts.”^13,14 That access disparity between rural and urban individuals is even more pronounced for low-income communities and communities of color, which have been disproportionately impacted by maternity ward closures. The impact of this widening inequity? Rural individuals face much higher risks of infant mortality and pregnancy complications, as extensive travel complicates routine prenatal care and can delay interventions, which exacerbates the cost and complexity of acute care.

The payer strategy: Short of building more maternity centers in rural counties, the most impactful actions available to payers may be to reach rural members where they are. That means partnering with community-based organizations for relevant supports and services, as well as increasing maternal telehealth and virtual care offerings. Comprehensive case management and frequent touchpoints with an experienced nurse (whether by phone or computer) can educate and engage members, around everything from managing comorbidities that could elevate complication risk to connecting them with a thoroughly vetted, in-network fetal care specialist if needed. Member care navigation also empowers rural individuals facing access barriers to best understand how — and when — to seek out in-person appointments or make the lengthy drive to a hospital, potentially identifying concerns before they become acute care episodes.

2x to 3x higher risk of maternal mortality for many members of color

The stat: Black women and American Indian and Alaskan Native (AIAN) women are far more likely to die from pregnancy-related complications than their white counterparts.15 The groups also face higher rates of preterm birth and low infant birthweight,¹⁶ two family-building complications that are among the leading causes of infant mortality.¹⁷ And though health equity became a national conversation during the global pandemic, research shows that racial disparities in maternal death rates actually widened in recent years.¹⁸

The payer strategy: The earlier a pregnancy is identified as higher-risk, the greater the opportunities for robust case management and risk mitigation. Consider, for instance, that Black women have higher rates, compared to white women, of obesity, hypertension, diabetes, stress and heart disease — all comorbidities that can elevate pregnancy risks.¹⁹ By leveraging data analytics to proactively identify higher-risk pregnancies and engage members before complications arise, payers can bolster the odds of avoiding those complications entirely, along with the associated health care costs and poor health outcomes associated with them.

36 to 45 years old is the most common age range for single individuals requesting donor sperm

The stat: Though it’s hard to exactly quantify, there are ample signs that more Americans are intentionally opting for single parenthood. Shifting social norms, an overall trend toward later parenthood, the mainstreaming of certain reproductive technologies (such as egg freezing) and regulatory changes are all driving momentum behind the trend. And some have argued that the ability to build a family, without first needing a romantic partner, is the next frontier in reproductive justice and true health equity. Cryos International, one of the largest sperm banks, reports that 54% of its customers are single parents by choice, most between the ages of 36 and 45.²⁰

The payer strategy: Equity-oriented health plans have already shaken free of the industry’s historical definition of infertility, which limits fertility coverage only to married, heterosexual partners who experience trouble conceiving through intercourse. And while more inclusive definitions are certainly worth celebrating, it’s clear there’s more work to be done. Both donor-assisted reproduction and single-parent adoption can be financially prohibitive without support. And, just like their partnered counterparts, individuals may find navigating the complex family-building landscape to be frustrating and confusing. Expanding family-building coverage to the broadest swath of members imaginable is a bold — and often incredibly cost-effective — strategy to walk the walk of offering a truly inclusive and equitable plan.

The ability to have the family you wish for has been called “a fundamental tenet of reproductive justice.”²¹ Health plans are uniquely positioned to identify and ease many of the health inequities that threaten that tenet. And, in doing so, they can help transform the act of family-building from a perilous, frustrating journey fraught with risks into one more centered on health, safety and joy.

Learn more about Optum Women's Health Solutions for Health Plans.

1. Kaiser Family Foundation. Racial disparities in maternal and infant health: Current status and efforts to address them. November 2022.
2. Reproduction Biology and Endocrinology. A review of disparities in access to infertility care and treatment outcomes among Hispanic women. January 2022.
3. Kaiser Family Foundation. Coverage and use of fertility services in the U.S. September 2020.
4. Maternal Child Health Journal. Racial/ethnic differences in the utilization of infertility services: A focus on American Indian/Alaskan Natives. 2019.
5. Journal of Women’s Health. Disparities in assisted reproductive technology utilization by race and ethnicity. June 2017.
6. Bendix, Aria. Babies born to Black mothers who use fertility treatments die at far higher rates than those born to white mothers. NBCNews.com, October 19, 2022. Accessed January 5, 2023.
7. AAMC Center for Health Justice. Polling spotlight: Understanding the experiences of LGBTQ+ birthing people. June 2022.
8. Kaiser Family Foundation. LGBT+ people’s health and experiences accessing care. July 2021.
9. UCLA, Williams Institute. Homelessness among LGBT adults in the US. May 2020.
10. Kaiser Family Foundation. LGBT+ people’s health and experiences accessing care. July 2021.
11. Ibid.
12. March of Dimes. Maternity Care Deserts Report: 2022. 2022.
13. U.S. Government Accountability Office. Maternal health: Availability of hospital-based obstetric care in rural areas. October 2022.
14. Kaiser Family Foundation. Racial disparities in maternal and infant health: Current status and efforts to address them. November 2022.
15. Ibid.
16. Centers for Disease Control and Prevention. Infant mortality.
17. Kaiser Family Foundation. Racial Disparities in Maternal and Infant Health: Current Status and Efforts to Address Them. November 2022.
18. Centers for Disease Control and Prevention. Prevalence of obesity and severe obesity among adults. Published February 2020.
19. Cryos International. 7 facts about single mothers by choice. February 2021.
20. Kaiser Family Foundation. Coverage and use of fertility services in the U.S. September 2020.