This document discusses barriers to Latina access to infertility services in the United States. It notes that Latinas experience infertility at higher rates than non-Hispanic whites but seek treatment at much lower rates. Key barriers include lack of health insurance (30.5% of Latinos are uninsured), low income, low education levels, cultural beliefs, language barriers, and fear of stigma. The document recommends policies like increasing community education to destigmatize infertility, improving provider cultural competence, expanding state insurance mandates to cover infertility services, and amending the Affordable Care Act to include infertility coverage.

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Inequality among the Childless: The Latino Infertility Services Access Disparity
By Lisa Tripp
CM 106
3/15/2014

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A total of 6.2 million Americans suffer from impaired fertility and fecundity, and
only 2.7 million of this group has ever sought treatment (Bitler and Schmidt, 2006). This
infertile treatment-seeking fraction is constituted primarily by “women and couples that are
white, college-educated, and affluent” (Bitler and Schmidt, 2006). So where does this leave
the Latina? Given that Latinas experience a 9.2% chance of infertility compared to a 6.9%
chance among non-Hispanic white females, the Latina infertility status is particularly
concerning. The passage of the Affordable Care Act in 2010 signified a great victory for
Americans, and even more specifically for Latinos across the United States in the realm of
health care. Although the implementation of the Affordable Care Act is now well
underway, Latina access to fertility services continues to remain at an all-time low in
comparison to all other races. A variety of factors influence Latina employment of fertility
services, the sum of which amount to Latina use at half the rate of other groups (Dawson,
et al., 2011). In order to create greater access for Latinas to fertility services, policy makers
and public health leaders alike must come together to implement policy specific to Latina
fertility needs, specifically taking into mind cultural, educational, financial, and insurance
inhibitors to care.
Infertility is a shockingly common condition affecting both men and women of all
races and socioeconomic statuses that often goes unspoken. A variety of sources of
infertility exist, however the fundamental categories include primary infertility, the
“[inability] to conceive a child after a year of having sex without birth control in women
under 35 years old or a 6 month time span in women 35 and older”, and secondary
infertility, applying to “women who cannot carry a fetus to full term, or to women who
have once, but cannot again” (Infertility, 2012). For Americans overall, “after 1 year of

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having unprotected sex, 15% of couples are unable to conceive, and after 2 years, 10% of
couples still have not had a successful pregnancy” (Infertility, 2012). Among these cases of
primary and secondary infertility, one third of cases can be attributed to women, one third
to men, and one third due to unknown causes (Infertility, 2012). Primary sources of
infertility among these women include endometriosis, polycystic ovarian syndrome,
primary ovary insufficiency, and uterine fibroids (Infertility, 2012).
Because of the popular conception that Latino fertility rates are high, little attention
is directed towards members of the Latino community struggling with infertility issues.
The popular stereotype of high Latino fertility does in fact hold merit, as per the lifetime of
1000 Latinas, as much as 30% more births than any other race occur (Total, 2012).
However, Latinas do experience a 9.2% chance of infertility, and in general, “both
infertility and impaired fecundity are more common among non-white women, among less
educated women, and among older women” (Bitler and Schmidt, 2006). Given the
fundamental, overarching ideas of basic human rights and equality, these statistics should
not be taken lightly, and infertile Latinas should certainly not per se be “swept under the
rug” as a result of their fertile counterparts.
Latina use of fertility services is extremely low compared to other groups in the
United States. Dramatically low Latina use of infertility services is statistically clear, as
among women actively seeking services, Latinas constitute only a mere 3.9%. Not only is
Latina infertility service use uncommon, but also significantly delayed, as on average
Latinas wait 1.3 – 5.3 years before actively seeking fertility services (Jain, 2006). The main
driving forces behind these two startling statistics include insurance status, education,
average income, and cultural, lingual, religious, and national origin barriers.

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Latina insurance status has an overwhelming impact on access to comprehensive
and costly fertility services. According to the National Health Interview Survey by the
Center for Disease Control, 30.5% of Latinos are uninsured (Summary, 2011). The
primary causes of lack of insurance among Latinos include job loss (17.1%), employer
refusal (12.5%), cost (51%), and loss of Medicaid (16.6%) (Becker, et al., 2005). These
statistics become even more relevant given the fact that among Latina women seeking
infertility treatments, 82% are uninsured, 13% receive Medicaid benefits, and only 6%
have private insurance (Becker, et al., 2005). Adding to the Latina insurance predicament
is the reality that “women with private health insurance coverage are 50% more likely to
receive services” (Bitler and Schmidt, 2006). Although the passage and implementation of
the Affordable Care Act stood as a beacon of hope for infertile and uninsured Latinas,
fertility services were not included in women’s reproductive services offered (Women’s,
2010). Unfortunately, these disparities come as no surprise, as the National Healthcare
Disparities Report by the Agency for Research Health and Equality reports that “disparities
related to race, ethnicity, and socioeconomic status pervade the American healthcare
system” (Jain, 2006).
In addition to insurance status, education status also has an unexpected impact on
Latina infertility rates. Among infertile women seeking treatment, 33% have a grade
school education or less, 39% have a high school education, and 28% have a college
education (Becker, 2005). Although an obvious, direct connection between lack of
education and infertility may not exist, possible theories may include decreased familiarity
and knowledge with medical concepts and family planning, or a lack of familiarity with the
healthcare system and services available. The connection between lack of education and

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increased prevalence of infertility may also simply be explained by a correlation with low
income.
Average income is perhaps the most important factor determining Latina access to
fertility services. According to the United States Census Bureau, the median household
income of Latinas in the United States is $38,039 (Money, 2012). Of women seeking
fertility services, 53% are unemployed, and 47% are employed (Becker, 2005). A dramatic
income-based infertility service access disparity exists, as “women with income more than
300% of the poverty line [are] 50% more likely to [receive] services” (Bitler and Schmidt,
2006).
Perhaps one of the greatest barriers to infertility services among Latinas is based in
culture. Although modern biomedicine is predominantly practiced today, deep seeded
cultural roots often play an important and complimentary role in self-diagnosis and
treatment among many groups. Homeopathic superstitions and treatments are vital for
many among the Latino community, and many experience “greater familiarity with and
confidence in alternative treatments as their primary source of care” (Dawson, et al.,
2011). For some Latinas, a popular homeopathic diagnosis for infertility is “cold womb,
the primary infertility-related diagnosis women received from practitioners of humoral
medicine” (Becker, 2005). “Cold womb” is popularly treated with “massage, followed by
herbal medicine, usually in the form of a hot tea, accompanied by staying warm, usually at
home” (Becker, 2005). Latina women struggling with infertility issues reported that they
had “been to a masseuse, or ‘sobadora,’ at some point in their quest for fertility” (Becker,
2005). Although these beliefs may be popularly held, their efficacy in treatment of

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infertility is questionable, and may be contributed to reduced use of biomedical infertility
services.
A second cultural barrier to infertility services for Latinas is language. Language
produces a significant healthcare barrier, especially in the United States, as 84% of Latinas
seeking fertility treatments are Spanish-speakers, 11% are bilingual, and 5% speak English
only (Becker, 2005). Language serves as a substantial barrier, as often medical
terminology does not translate perfectly between languages, and much of diagnosis and
treatment plans may be lost in translation on both the part of the doctor and the patient.
In addition to homeopathic alternatives and language barriers, religion also serves
as a significant cultural barrier for some in the journey toward overcoming infertility in the
Latina community. According to the Hispanic Evangelical Association, roughly 70% of
Latinas identify as Roman Catholic, which may hold cultural implications in seeking
fertility treatments – in general Catholics oppose IVF treatments (Murray, 2014).
National origin also serves as a barrier in culture to seeking infertility services for
Latinas. Women born and raised in the United States in general are “more assertive in
seeking care and have an overall plan that they intend to pursue to become pregnant”
(Becker, 2005). In contrast to US-born Latinas, immigrant Latinas are more likely to
“express more gratitude for the care they receive and take less initiative in considering
other biomedical possibilities, and most do not have a plan that goes beyond what clinics
can offer them” (Becker, 2005).
Lastly, but perhaps most vital to Latino families struggling with fertility issues, is
cultural resistance to infertility services based in fear. Infertility is commonly seen as a

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threat to the survival of Latino families, as the “fear of knowing which member of the
couple is responsible for infertility” deters Latino couples from seeking fertility treatment
(Dawson, et al., 2011). This attitude is further magnified by intense importance and
centrality of children to Latino families.
Given the various seemingly insurmountable barriers Latinas face in seeking
infertility services, infertility in the Latino community has impacts far more reaching than
the simple inability to create children. As can be inferred from the cultural barrier of fear to
the family structure, untreated infertility has a significant impact on marriages. Among
many Latino families “women and men believe that a child is the basis of the marital
relationship: a child is thought to create a bond between the couple and legitimize the
relationship” (Becker, 2005). In the midst of infertility “childless marriages are considered
failures, and there is a widespread expectation that relationships will end if no children are
born.” (Becker, 2004). Not only does infertility threaten Latino relationships, but also may
result in lowered self-worth and emotional detriment. Latinas struggling with infertility
often “become demoralized by repeated failure to conceive and [experience] increased
fault-finding with [their partners] (Becker, 2005). Among Latinas interviewed at fertility
clinics, the majority express “consistent fatalism about fertility” (Dawson, et al., 2011).
Adding to the emotional desparity, “only a few women have jobs they find interesting, and
no one thinks a good job will be an acceptable alternative to having children – each
continues to hope for a conception and reports feeling desperate at the idea that she might
not conceive” (Becker, 2005).
Although a menagerie of barriers exist to seeking infertility services, and the effects
of these barriers are transcending, a variety of avenues exist for individuals seeking fertility

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services and treatment - though none are simple or without significant financial cost. Most
familiarly recognized among fertility service sources are hospital-based and private
practice fertility clinics, which tend to not only be more invasive and advanced, but also
the most expensive route to achieving fertility, almost always necessitating comprehensive
insurance coverage. Other less expensive sources of infertility care, which may be the only
source of assistance to low-income, uninsured, and entirely Spanish-speaking Latinas
include minor and noninvasive care provided through free clinics, infertility clinics at
county hospitals funded under Title 10 funds primarily staffed by medical students and
residents, and non-profit grants and scholarships. The cost of fertility services in the United
States is astronomical, as the “mean direct cost for a single in vitro fertilization cycle is
estimated at $9,547”, roughly 25% of the average Latino annual income (Bitler and
Schmidt, 2006). If fertility services are successful, birth after in vitro fertilization may cost
from $44,000 to $212,000”, reaching from 115 to 557% of the annual Latino income,
making such services almost completely economically unfeasible for most (Pratt, 2004).
Given the reduced cost of $3,518 for a single IVF cycle in 25 other countries, the United
States has a long way to go in enacting public health policy to make infertility services
accessible for many groups (Bitler and Schmidt, 2006). Adding to the need for reform is
the fact that “although IVF growth and technology continues to improve, it remains a
primarily privately funded treatment modality (fee-for-service model)” (Bitler and
Schmidt, 2006).
In terms of payment, insurance coverage for infertility services throughout the
United States as a whole remains patchy and inadequate at best. A majority of insurance
plans available in the US exclude infertility services as medically unnecessary, not

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medically proven, and working to treat a preexisting medical condition (Bitler and
Schmidt, 2006). The US falls behind many other developed countries in this respect, who
“provide coverage for infertility services (including IVF) within their national health
plans” (Bitler and Schmidt, 2006). Despite the shocking insurance disparities the US faces
in comparison to other developed countries, selected states have enacted mandates to
ensure inclusion of fertility service coverage in all insurance plans offered. Since the first
state mandate enactment in 1977, 15 total states have participated, including Arkansas,
California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana,
New Jersey, New York, Ohio, Rhode Island, Texas, West Virginia (Bitler and Schmidt,
2006). Although the 15 state mandates that have been enacted signify process for the
United States, little progress is made for the Latina, as the majority of Latinas reside in
California, Arizona, New Mexico, and Texas (Latino, 2000). Additionally, some state
mandates do not require coverage of IVF, which would perhaps be the most important
fertility service to cover, and do not include Health Maintenance Organizations (HMOs)
(Bitler and Schmidt, 2006). Despite state mandates for infertility service coverage, clinics
are more than likely “attracted to areas where women are more educated and wealthy, but
there is no evidence that clinics are attracted to places where mandates are in effect” (Bitler
and Schmidt, 2006). Even with mandates in place, “disparities in access to treatment exist
along racial and socio-economic status dimensions”, as with all other health parameters in
the United States (Bitler and Schmidt, 2006).
Given the multiple factors contributing to Latina lack of access to fertility services
and treatments, immediate consideration of policy amendments is necessary. The first
public health policy recommendation to be taken into consideration is an increase in

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education. Education must be put in place on the community level in order to de-stigmatize
infertility among Latinos. De-stigmatization of infertility within the Latino community will
serve to not only improve the mental health status of Latinas suffering with infertility, but
also help to stabilize the family structure, reduce infertility-related threats to marriages, as
well as generate greater community awareness and support. Community based education
also must be improved by increasing awareness of the biomedical causes of infertility, as
well as the biomedical options available to treat the condition, in addition to the culturally
popular homeopathic medical model. In order to achieve these types of education within
communities, I suggest state-by-state governmentally funded educational materials to be
distributed for general population and patient access throughout low income community
clinics. An effort to incorporate infertility into health education within high schools may
serve to both familiarize and de-stigmatize the issue before the majority of Latinos reach
prime child-bearing years. Not only must education be provided within the community, but
also within the health care field. Health-worker based education must be put in place in
order to increase cultural and lingual awareness, which will encourage clear, effective, and
appropriate communication between providers and patients. I suggest public health policy
to mandate language education for undergraduate pre-health students, as well as required
minority community clinic service as a prerequisite for advanced health licensure.
In addition to mandated community and health service based education, public
health policy must be put in place in order to increase state mandates of insurance coverage
of infertility services. As only 15 states currently mandate that insurance companies
include coverage of infertility services, an overarching federal mandate must be considered

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to require all states to require coverage of these services, especially as two of the most
populously Latina states, New Mexico and Arizona, are not currently mandated.
In order to address the discrepancies discovered in Latina access to infertility
services, an amendment to the Affordable Care Act must be considered. As the Affordable
Care Act currently does not include coverage of infertility services in the women’s
reproductive services offered, changes in order to include coverage must be made, as the
ACA provides a main source of affordable insurance for many Latinas. Amendments to
include the coverage of undocumented immigrants must also be immediately considered,
as infertility service options for this group exist only through independent funding.
A final public health policy, which must be considered in the absence of an
amendment to the Affordable Care Act, would increase the amount and complexity of
fertility services provided by low income clinics as an avenue for undocumented
immigrants and those who cannot afford the insurance provided by the ACA. Increased
funding to make increased complexity and abundance of fertility services possible would
be governmentally subsidized.
Overall, the disparity evident in Latina access to infertility services arguably
borders on a denial of fundamental human reproductive rights. Public health policy
implementation to address the primary barriers to Latina infertility service access must be
immediately considered. Lack of immediate action may serve to perpetuate preexisting
issues within the Latino community, including marital stress, lowered individual self-
worth, and emotional detriment.

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