Race and Infertility Care

Several research assistants and I spent last summer looking at websites from virtually every US fertility clinic.  One of the things we recorded was the race of any babies pictured on the first page of the clinics’ websites.  I have no background in critical legal studies or critical race theory, so I am probably not the best person to do this study, but I was looking at other advertising issues on the website, and I had read that minorities use assisted reproductive technologies at a much lower level than Whites, despite experiencing higher rates of infertility and even when states mandate fertility insurance (which should control for wealth effects).

 I was surprised by the results, which are included here.  It turns out that the picture of fertility care in America on websites is quite literally a picture of White doctors helping patients have White babies. 

Of the 294 websites that presented images of babies, 62.93% (n=185) presented pictures of only White babies, while 1.02% (n=3) presented images of only Black babies; 0.34% (n=1) had an image of only a Latino baby; and 1.02% (n=3) had a picture of only an Asian baby. If we include instances where White babies appear along with babies of other races, 97.28% (n=286) of websites with pictures of babies have pictures of White babies. 

The races of fertility doctors are similarly lopsided.  We believed we could determine the races of 1124 reproductive endocrinologists on clinics’ websites. Of those physicians, 79.89% were White, 2.14% were Black, 4.27% were Latino, 8.27% were Asian, and 5.43% were of other races.

What should make of these disparities?  I’m not sure, and I am anxious for your thoughts.  But, it could help explain why minorities seek fertility care at a lower rate than White patients.  If having a doctor that is the same race is important to people or if being represented in advertising for a service is significant, these findings might shed light on why certain races are less likely to go to a fertility doctor.

Comments

[Ganger]

Interesting question. I don't know if you completely adjust for wealth effects by looking at the states that have insurance coverage. Does it cover 100% of the care? Also, unlike other medical conditions, going to a fertility clinic, if successful, means you will have a substantial cost over the next 18 + years raising the child. Most of that cost is out of pocket. Generally, poor people do not have babies when they are 45, which is what a lot of the clientele in some of the fancier clinics consists of.

[David B.]

I'm curious how you can tell if a baby is "Latino" by looking at a picture.

[David B.]

I'm also curious about why you summarize 80% white doctors and 20% non-white doctors as "white doctors." And, is these percentages different than the percentages of reproductive technology specialists from different groups? If not, why would there websites reflect otherwise?

[I. Glenn Cohen]

Great project Jim. If you have not done so already, you may also want to look at Dov Fox's paper on Racial Classification in ART available here http://ssrn.com/abstract=1432666 (though a few years old now). Can't wait to read your new paper!
Glenn

[Jim Hawkins]

David B. you are totally right that we might have misclassified people's races.
My thought in doing it, however, was that if we were likely to make mistakes, so were potential patients, and I don't know why we would be more likely to make mistakes than potential patients, so the results still seem worth mentioning.

I guess I was a little cavalier to say that 20% of non-white doctors still make the picture one of whiteness, but hey, it's a blog! The percentages of minorities are far off from the representation in the general population of the US.

[Daniel S. Goldberg]

To the best of my knowledge, racial concordance between patients and physicians is an enormously important factor in establishing trust, continuity of care, and a host of other factors that are relevant to health outcomes. (There's also a lot of literature operationalizing many of these variables under the aegis of social capital).

I have no idea if such concordance mediates reproductive medical utilization in general or fertility interventions in particular, but the general topic of patient-provider concordance is extremely well-studied. It is actually considered a priority area of research among NCMHD Centers of Excellence (at least, I know it is here at our local Center for Health Disparities research).

[David B.]

Daniel, is it "racial" or is it "black white?" Do whites care if their doctor is Asian, and vice-versa?

[Iudex oeconomicus]

1. The level of education in the different groups might play a role. If whites get more years of education than African-Americans and Hispanics on average, they're probably more likely to put off starting a family to an age where fertility becomes an issue. (Ideally you would want to know the composition of the population of potential customers of fertlity clinics.)

2. How do the racial percentages of reproductive endocrinologists compare to physicians in general (or to medical school graduates)? Without that, I don't think your data about doctors are telling us very much.

[R. Alta Charo]

Utilization of ART correlates with a number of variables that, themselves, interrelate. These include age of attempted conception (older couples have more difficulty conceiving without ART, especially those with older women). This in turn correlates with higher education attainment (thus delaying childbearing) and that, in turn, correlates with higher income, thus spare cash for elective medical care or (where available) access to covered care because the primary holds health insurance. And this is not the complete list. So if anything, I am surprised that whites are not more overrepresented in the patient population than they are, given their over-representation in higher income/higher coverage/later marriage or childbearing categories. As to the doctors, it would be relevant to look at the age distributions, as the older doctors are, as a group, whiter and more frequently men. In the younger demographic you may find a somewhat different mix. And even there, it is relevant to look at the specialty areas, as many take extra years of training at lower pay, thus becoming less attractive to those needing to begin to pay off loans or who wish to start their families sooner.

[Daniel S. Goldberg]

David,

I think there is data across census categories of race (including Asian/Asian-American), but this is not my central area of research.

[r. alta charo]

I just saw this on SSRN - it might be relevant:

HEALTH CARE LAW & POLICY eJOURNAL

"Patients' Racial Preferences and the Medical Culture of Accommodation" Free Download
UCLA Law Review, Vol. 60, No. 2, 2012
Fordham Law Legal Studies Research Paper No. 2222227

KIMANI PAUL-EMILE, Fordham University School of Law
Email: [email protected]

[Margaret Ryznar]

That is very interesting.

[concerned_citizen]

"What should make of these [website image] disparities? ... could help explain why minorities seek fertility care at a lower rate than White patients. "

Hi Jim - interesting work. But (and I apologize both for being late to the comments here and for not yet having read your full paper), do you have any background information yet on what percentage of people utilizing ART do so on the basis of having visited websites?

My strong suspicion is that many if not a majority of people utilizing ART are doing so on the advice of and recommendation of some other health care provider (which normally includes recommendation of or referral to a particular ART clinic).

I could be wrong about the above. But without some data provided on how it is that people learn of - and select - their ART providers, guessing about website presentation would seem to be no more than guessing.

[RS Gold]

I liked your article, I will share your article to everyone!!