In summary, in this large cohort of self-reported fertility care satisfaction, we found that after adjustment of confounders, Black patients reported higher doctor satisfaction and East Asians reported borderline lower clinic satisfaction. Despite some differences in unadjusted satisfaction among multiple racial/ethnic groups, most differences did not persist after adjustment for demographic and patient satisfaction confounders. These patterns are particularly interesting given the known disparities in ART outcomes, with Black patients consistently being found in literature to have worse outcomes than other racial groups.(1) Overall, our data are reassuring in that minority groups do not appear to report worse satisfaction scores with fertility care, though more investigation is needed on both fertility patient satisfaction as well as outcome disparities in outcomes by race/ethnicity.
Comparison with existing literature
Prior literature has consistently reported disparities in ART outcomes, with minorities and particularly Black patients having poorer outcomes when compared to Caucasian patients.(1, 2) An analysis of 38,309 cycles using SART CORS data found increased miscarriage rate and decreased live birth rate compared to Black women compared to white women, even after controlling for uterine and tubal factor disease.(3) Another study of 138,927 SART ART cycles found increased fetal loss rate in Black women compared to other racial groups.(6) Several studies have reported significantly lower implantation, clinical pregnancy, and live birth rates in Black ART patients (3, 19), though not all studies have found these conclusions.(20, 21) It has been hypothesized that an increased prevalence of leiomyomas and possible difference in baseline diagnoses of BMI may contribute to these dipartites, though some studies controlling for these factors have continued to find disparities. Several more recent studies have continued to report disparities in Black ART outcomes; a recent analysis of 7,002 SART CORS cycles found that Black race was associated with lower live birth rate in frozen embryo transfer cycles (aRR 0.82; 95% CI 0.73–0.92) and a higher clinical loss rate (aRR 1.59; 95% CI, 1.28–1.99) compared with White women. Additionally, Black women were found to have a lower rate of implantation compared to other racial groups even in PGT cycles.(4) Another study of 1,601 donor embryo transfer cycles from 2008–2015 found that Black recipients had a lower probability of live birth than white donors and recipients (aRR 0.84; 95% confidence interval, 0.71–0.99), while live birth disparities were not found in Hispanic, Asian, and other races compared with white recipients.(5)
Disparities in ART outcomes for Asian and Hispanic groups have also been reported. The prior referenced study of over 130,000 ART cycles from SART found that odds of pregnancy were reduced for Asians (0.86) and live birth odds were reduced for Asians (0.90), Black (0.62), and Hispanics (0.87).(6) Another SART study of 25,843 white and 1,429 Asian women found that Asian women had significantly decreased cumulative pregnancy rate and live birth rate when compared to white women, and that Asian ethnicity was an independent predictor of poor ART outcomes after adjustment for confounders.(22) Multiple other studies have also reported worse ART outcomes in Asian patients, including both large database and smaller independent center studies.(23–25) Studies on SA populations specifically have reported inconsistent information on disparities, including some studies reporting worse outcomes in this population, while other have reported equivalent outcomes.(7, 8) One study of 196 Caucasian and 117 South Asian women reported equivalent outcomes in frozen embryo transfers, but significantly lower outcomes in fresh transfers, suggesting that the relationship between race/ethnicity and ART outcomes may depend on ART procedure type.(26) Studies on Hispanic patients have been limited by sample size; in the SART Writing Group 2010 paper, live birth rates from ART were 13% lower for Hispanic than for white women.(6) However, a study of the military health care system found no significant differences in IVF outcomes for Hispanic and white patients.(27) More investigation is warranted in this population.
It is also important to note that the data on this subject of racial/ethnic disparities in ART outcomes may be limited by incomplete report of race/ethnicity in datasets used for analysis on this subject (28), leading to possible bias in the results. Additionally, studies have typically reported minority groups of Black, Asian, and Hispanic, even though these groups may contain substantial heterogeneity and additional subgroups. Additionally, data suggests that access to fertility care is also adversely affected by race/ethnicity, as infertility care is accessed at a higher rate by non-Hispanic white women with higher socioeconomic parameters, and at a lower rate for Hispanic women.(29, 30)
Literature on patient perspective on self-reported fertility care satisfaction by race/ethnicity is extremely limited, despite the more extensive literature on disparities in outcomes as above. A study of 1,460 patients at an academic fertility center in Illinois found that Black women (14.7%) were more likely to report that race was a barrier to getting fertility treatment compared with White (0.0%), Hispanic (5.1%), and Asian (5.4%) women, though satisfaction with fertility care was not assessed.(9) A prior FertilityIQ analysis of 7,456 women from 2015–2018 reported a number of factors associated with positive patient-reported experience (including positive results, being treated like a human instead of number, good communication and expectation setting by doctor, shorter wait times, scheduling, and billing satisfaction).(10) However, stratifications by race/ethnicity group were not available in this analysis, and we have updated this data with these stratifications as well as a substantially large sample size. A few other studies have investigated patient satisfaction in fertility care, with an older study of 1,499 patients in the Netherlands reporting high general patient satisfaction (94%), with waiting times, information provision, and emotional support the least positive aspects of care.(11) Prior literature includes smaller studies that have investigated multiple aspects of satisfaction with fertility care, including general patient satisfaction and provider perception (12–14), though study on fertility satisfaction by ethnicity is very limited.
In other fields of medicine, a large study of around 250,000 Press-Ganey surveys found that Asian, younger and female patients provided less favorable ratings than other race/ethnicity older and male patients.(15) This is in line with our findings of EA reporting lower clinic satisfaction than other groups. Other large studies have suggested that minority groups may report lower satisfaction than Caucasian groups with medical care, including a European study of 138,878 cancer patients (16) and a study of 7,795 patients on satisfaction with physician, nursing, and overall care during hospitalization.(17) In contrast, a smaller study of 527 surveys found no differences in outpatient pediatric surgical care by race/ethnicity or socioeconomic are. These findings from other studies may not be completely generalizable to fertility care given the differences in patient population and higher percentage of self-pay patients in fertility. In general, given the limited research, more research in patient satisfaction by race/ethnicity in medicine (not just fertility care) is warranted.
Our analysis is the largest and one of the first to investigate patient satisfaction in fertility care by ethnicity. We found that despite disparities in ART outcomes, Black patients were the only group to rate their physician satisfaction significantly higher than other groups. EA were the only group to rate their clinic satisfaction as significantly lower than other groups, while other disparities were not seen after adjustment for confounders. As expected, there were baseline differences between the groups in terms of demographic and clinic satisfaction characteristics. Though some disparities were found on univariate analysis, after adjustment of all confounders, most differences in unadjusted satisfaction scores no longer persisted with the exceptions above. Interestingly, Black patients did not report lower satisfaction despite literature suggesting worse ART outcomes in this population. Overall, data is reassuring in that minority groups do not appear to have worse satisfaction with fertility care, with the exception of EA for clinic satisfaction. However, more investigation is needed into the underlying disparities in fertility care for minority populations.
Strengths and Limitations
The strengths of this analysis include the large sample size, detailed information available on potential confounders, and the novelty of the subject matter. FertilityIQ is the largest database of patient satisfaction on fertility care in the United States, and our large sample size is an asset in allowing seven categories of racial/ethnic stratification. Additionally, the prior literature on patient satisfaction by race/ethnicity in fertility care is extremely limited, and ours is by far the largest study in this area. We were also able to investigate racial/ethnic groups including Middle Eastern and Native American which have traditionally not been as frequently studied (though sample sizes were limited for these groups), and were also able to study East Asian and South Asians separately (as this is a heterogeneous group which has often been studied as one racial category). FertilityIQ also collects extensive demographic information which as used in multivariate analysis, as some of these factors may be confounders for patient satisfaction.
The limitations of the study include its cross-sectional nature, self-reported voluntary survey data which may be subject to bias in terms of recall bias or who chooses to fill out an online survey, and small but statistically significant differences that may not be clinically significant (as a result of large sample size). The survey was available online but not sent out to patients, so patients had to choose to go to the website to voluntarily, which may lead to response bias. Additionally, there may be cultural differences in terms of who chooses to fill out a survey and how different groups respond to survey questions, or cultural differences in expectations of care. It is important to note that given known disparities in access to care, this survey can only be interpreted in the context of those who were able to obtain fertility care. The survey was also limited to English speaking patients, which is a potential bias in the analysis by not capturing non-English speaking patients. We also had to exclude multi-racial respondents from the analysis due to difficulty analyzing multi-racial data; however, as the population of multi-racial individuals will continue to increase, is it important to develop ways to adequately analyze this population. Though the data must be interpreted with caution, our large sample size gives us confidence in our results for the different racial/ethnic groups studied.