Date of Award

Spring 2023

Document Type

Open Access Dissertation


Health Services and Policy Management

First Advisor

Peiyin Hung


The overall objective of this research study was to examine the association between fertility treatments and maternal and infant birth outcomes, and to understand what role insurance type plays in these associations.

This retrospective statewide cohort study utilized population-based birth certificate data from January 2018 – December 2021in South Carolina, linked to all-payer claims data for outpatient services, inpatient admissions/discharges, and emergency department visits. Key exposure variables included insurance type and fertility treatment, depending on Aim. Key outcomes of interest included fertility treatment (Aim 1); maternal outcomes (Aim 2) including severe maternal morbidity, cesarean delivery without medical indication, elective labor induction, gestational diabetes, gestational hypertension, and placenta complications; and birth outcomes (Aim 3) including preterm birth and low birthweight.

Descriptive analyses, including frequency and proportions, were calculated and used to report demographic and clinical characteristics for each study cohort. Fisher’s exact tests or Pearson’s Chi-square tests were used to compare demographics for nominal, categorical variables while Mantel-Haenzsel Chi-square tests were used to compare demographic variables that were ordinal. Bivariate and multivariable logistic regression analyses were employed to assess the associations for each Aim, clustering at the hospital level. Propensity score matching was used as a sensitivity analysis for Aim 2- 3.

Of 4,981 infertile women with any visits to hospital-based settings in January 2018-December 2021 (Aim 1 population), 1,860 received fertility treatment to conceive while 3,121 had not received fertility treatment. The odds of receiving fertility treatment among infertile women with Medicaid, other public insurance, and no insurance were 25% (Odds Ratio [OR], 0.75; 95% Confidence Interval [CI]; 0.61-0.92, P = 0.006), 34% (OR, 0.66; 95% CI, 0.56-0.77; P15 years of age with live births between January 2018 – December 2021 (Aim 2-3 population) after matching, women who underwent fertility treatment (n = 1,860) did not have a higher likelihood of adverse maternal and infant outcomes than women who conceived naturally. Upon assessing the role of insurance type, women who underwent fertility treatment and had private insurance were 10.0% more likely to have gestational hypertension (0.01; 95% CI, 0.00-0.02; P

The finding that the likelihood of receiving fertility treatment significantly decreases among infertile women with Medicaid, other public insurance, or no insurance compared to infertile women with private insurance suggests that policy reforms focused on increasing insurance coverage for fertility treatment in South Carolina might help address an unmet medical need for infertile women by increasing access to fertility treatment, and thus increasing the live birth rate among infertile women. That fact that fertility treatments were not negatively associated with maternal and birth outcomes suggests that fertility treatment may not be adversely related with maternal and infant outcomes, though insurance type may play an important role in these associations. Policy initiatives on improving maternal and infant outcomes among women with infertility should be aimed at expanding insurance coverage for fertility treatment.


© 2023, Chelsea Mencio Norregaard

Available for download on Thursday, May 15, 2025