Despite being disproportionately affected by infertility, African American women seem to have a limited level of infertility knowledge. In a comparison to the original study by Bunting et al., our participants had a lower level of infertility knowledge (score 38%) when compared to their total number of women (n = 8355, average score 59.1%, 79 countries). Our participants also had a lower knowledge score in comparison to their female participants specifically representing the USA (N = 427, average score approximately 65%) .
While infertility is a disease of many etiologies, a commonly cited cause of infertility among AA women is tubal factor, which is often secondary to a history of sexually transmitted infection or pelvic inflammatory disease . Interestingly, only 45.6% of total participants in our study knew that sexually transmitted diseases could adversely affect fertility. This reflects a concerning lack of sexual health awareness among the women in our study. Our results are consistent with those found by Deatsman et al., who found that AA women were less aware, in comparison to other racial groups, that a history of STI can be risk factor for infertility .
As delayed childbearing has become the norm in our society, patient awareness of how age affects infertility is becoming increasingly more important . In our study, 24% percent of participants knew that a woman’s fertility decreases after the age of 36 years. Furthermore, only 11.5%of subjects knew that the probability of conceiving is different between a woman age 30 vs. 40 years. This was also consistent with Deatsman et al’s study, showing AA women were significantly less aware of the impact age has on infertility .
Obesity (defined as BMI > 30) is another health condition disproportionately affecting African Americans in the US. In the US approximately 56.5% of African American women are obese compared to 35.3% of Caucasian American women. When including those who are overweight (defined as BMI 25–30), the percentage surges to 82% of AA women and 63.5% of CA women . The survey instrument included the threshold of “greater than 28 pounds overweight”, as this was previously determined in a preliminary study by Bunting et al., to be the point at which there is a significant association with infertility . In our study, 57% of participants correctly associated increased difficulty with fertility and being overweight by > 28 lbs. This is of clear concern as obesity is a modifiable risk factor and the vast majority of AA women have a BMI > 25 .
Infertility treatment beliefs
Overall, our subjects had a relatively neutral response to both negative and positive treatment beliefs. There was no significant difference in treatment beliefs based on age, education level, and parity. Interestingly, those with a history of infertility therapy were significantly more likely to agree with negative treatment beliefs. Detailed questions to characterize the experiences of those who reported a history of infertility treatment were not included in the survey. Therefore, this finding may be due to a personal history of poor success with treatment. However, this finding also raises questions of how their infertility care experiences may differ from other racial groups. It is important to consider the commonly found mistrust of the US healthcare system held among many AAs. This general mistrust is often attributed to the AA response to institutionalized racism and the history of medical maltreatment in the US . It is possible that these negative beliefs result from underlying mistrust rooted in AA history.
Strengths and limitations
Our study is unique because it includes solely women who self-identify as African-American or black, which is currently the third largest racial ethnic group in the US . This group is often underrepresented in the literature, especially in qualitative studies focused on infertility. Further strengths include the diversity of our subjects, with respect to age, parity and education levels.
There were limitations to this study, which may affect the generalizability of our results. Our survey was administered to a convenience sample at a single location in a safety net hospital. The results of our study may not reflect the infertility knowledge and beliefs of privately insured AA women, those with a higher socioeconomic status or those living in the suburbs, rural or other urban areas. We did not include insurance type as a part of the survey instrument. Therefore, a sampling bias may have been created as the majority of the patients at our clinic are insured by Medicaid or are uninsured. Though we are unable to incorporate specific insurance types per participant, we were able to calculate the proportion of insurance types used across our entire clinic patient population (Fig. 1). Also not included in the survey instrument, were detailed questions to characterize experiences of those who reported a history of infertility treatment.
Unfortunately, the participation rate was not tracked and therefore cannot be calculated or analyzed. However, most patients who were invited to participate in this study completed the survey. Additionally, a sample selection bias may have been created on exceptionally busy clinic days when recruitment occurred less often. Lastly, the sociodemographic composition of our patient population differed greatly from the original study and the proportion of African American representation in the original study was not published. Due to this, we were unable to make a stronger/statistical comparison. Though this is a limitation, it also underscores our disposition to further characterize this subpopulation’s perspective of infertility.