J Korean Med Sci.  2023 Sep;38(38):e293. 10.3346/jkms.2023.38.e293.

Socioeconomic Factors and Abortive Outcomes of Clinical Pregnancy After Embryo Transfer in the Setting of Universal Health Insurance Coverage of IVF

• Kim JH
• Kim S
• Ryu KJ
• Park H
• Kim YJ
• Choe SA

• KMID: 2546216
• DOI: http://doi.org/10.3346/jkms.2023.38.e293

Abstract

Background
In vitro fertilization-embryo transfer (IVF-ET), an expensive option for infertile couples, started to be fully covered by the National Health Insurance (NHI) from October 2017 in South Korea. We investigated the association between woman’s socioeconomic status (SES) and abortive outcomes in pregnancies after IVF-ET in the setting of universal coverage of the treatment.
Methods
Using the NHI database in South Korea, we conducted a retrospective cohort study of all women who achieved clinical pregnancy after ET between October 2017 and February 2019. A total of 44,038 clinical pregnancy episodes of 29,847 women who underwent ET were analyzed. We used employment status, income in percentiles, and living in the Seoul capital area as indicators of SES. Relative risks (RRs) for abortive pregnancy outcomes were calculated for each socioeconomic stratum, using log-binomial regression models included woman’s age, body mass index, fasting blood glucose, fresh ET, month of ET, and history of smoking.
Results
While most pregnancy outcomes were live births (n = 30,783, 69.9%), 11,215 (25.5%) cycles ended with abortion or early pregnancy loss, 1,779 (4.0%) cycles were ectopic pregnancy, 45 (0.1%) were coded as molar pregnancy, and 224 (0.5%) were fetal death in utero or stillbirth. The risk of overall abortive outcomes was higher when a woman was unemployed (adjusted RR, 1.08; 95% confidence interval [CI], 1.05–1.11) or living in a nonSeoul capital area (1.11; 95% CI, 1.08–1.14). The association between relative income level and abortive outcomes was close to null. Living outside Seoul capital area was associated with the greater risk of abortive outcomes especially in younger women.
Conclusion
Unemployment and living in non-capital areas were associated with a higher risk of abortive outcomes among pregnancies after ET, even in the setting of universal coverage of IVF-ET. This suggests potential impact of socioeconomic position on the IVF-ET pregnancy.

Keyword

Pregnancy; Socioeconomic Status; In Vitro Fertilization; Embryo Transfer; Live Birth

Figure

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  Fig. 1 Effect modification by women’s age (< 35 or ≥ 35 years) in the association of employment status and living in the SCA with risk of abortive outcomes in 44,038 clinical pregnancies after embryo transfer between November 2017 and February 2019.SCA = Seoul capital area.aP for heterogeneity < 0.05

Reference

1. Papageorghiou AT. Insights into determinants of health. BJOG. 2020; 127(4):431–432. PMID: 32048464.

2. Hayward MD, Hummer RA, Sasson I. Trends and group differences in the association between educational attainment and U.S. adult mortality: implications for understanding education’s causal influence. Soc Sci Med. 2015; 127:8–18. PMID: 25440841.

3. Aizer A, Currie J. The intergenerational transmission of inequality: maternal disadvantage and health at birth. Science. 2014; 344(6186):856–861. PMID: 24855261.

4. Stirbu I, Kunst AE, Mielck A, Mackenbach JP. Inequalities in utilisation of general practitioner and specialist services in 9 European countries. BMC Health Serv Res. 2011; 11(1):288. PMID: 22040155.

5. van Doorslaer E, Masseria C, Koolman X. OECD Health Equity Research Group. Inequalities in access to medical care by income in developed countries. CMAJ. 2006; 174(2):177–183. PMID: 16415462.

6. Choe SA, Yoo S, JeKarl J, Kim KK. Recent trend and associated factors of harmful alcohol use based on age and gender in Korea. J Korean Med Sci. 2018; 33(4):e23. PMID: 29318790.

7. Al-Hindi MY, Aljuhani H, Alnajjar AR, Alessa S, Alqurashi M, Faden YA. Examining the association between parental socioeconomic status and preterm birth using multidomain social determinants scale in a tertiary care center in Saudi Arabia. Cureus. 2020; 12(9):e10506. PMID: 32963925.

8. Hayashi I, Takakura K, Yamaguchi K, Sumitomo M, Suzuki M, Sumitomo A, et al. Association between socioeconomic status and small-for-gestational-age in Japan: a single center retrospective cohort study. J Obstet Gynaecol Res. 2020; 46(1):110–118. PMID: 31392834.

9. Luo X, Liu L, Gu H, Hou F, Xie X, Li X, et al. Pathways linking socioeconomic status to small-for-gestational-age (SGA) infants among primiparae: a birth cohort study in China. BMJ Open. 2018; 8(6):e020694.

10. Keenan-Devlin L, Smart BP, Grobman W, Adams E, Freedman A, Buss C, et al. The intersection of race and socioeconomic status is associated with inflammation patterns during pregnancy and adverse pregnancy outcomes. Am J Reprod Immunol. 2022; 87(3):e13489. PMID: 34958140.

11. Korea Health Industry Development Institute. Infertility-ART. Accessed January 23, 2023. https://www.medicalkorea.or.kr/en/infertilityart .

12. Kim M.. National policies for infertility support and nursing strategies for patients affected by infertility in South Korea. Korean J Women Health Nurs. 2021; 27(1):1–5. PMID: 36311986.

13. Ministry of Health and Welfare (KR). Expansion of coverage of health insurance for infertility treatment. Updated 2019. Accessed October 6, 2021. https://www.mohw.go.kr/react/al/sal0301vw.jsp?PAR_MENU_ID=04&MENU_ID=0403&page=1&CONT_SEQ=348915 .

14. Kim S. Reproductive technologies as population control: how pronatalist policies harm reproductive health in South Korea. Korean J Women Health Nurs. 2019; 27(2):1610278.

15. Health Insurance Review & Assessment Service (KR). Statistics of medical procedures. Updated 2022. Accessed February 15, 2022. http://opendata.hira.or.kr/op/opc/olapDiagBhvInfo.do .

16. Norsker FN, Espenhain L, A Rogvi S, Morgen CS, Andersen PK, Nybo Andersen AM. Socioeconomic position and the risk of spontaneous abortion: a study within the Danish National Birth Cohort. BMJ Open. 2012; 2(3):e001077.

17. Kim I, Kim MH, Lim S. Reproductive hazards still persist in the microelectronics industry: increased risk of spontaneous abortion and menstrual aberration among female workers in the microelectronics industry in South Korea. PLoS One. 2015; 10(5):e0123679. PMID: 25938673.

18. Park C, Kang MY, Kim D, Park J, Eom H, Kim EA. Prevalence of abortion and adverse pregnancy outcomes among working women in Korea: a cross-sectional study. PLoS One. 2017; 12(8):e0182341. PMID: 28850585.

19. Cai C, Vandermeer B, Khurana R, Nerenberg K, Featherstone R, Sebastianski M, et al. The impact of occupational activities during pregnancy on pregnancy outcomes: a systematic review and metaanalysis. Am J Obstet Gynecol. 2020; 222(3):224–238. PMID: 31550447.

20. Reynolds CM, McMahon LE, O’Malley EG, O’Brien O, Sheehan SR, Turner MJ. Maternal employment and pregnancy outcomes in a large European maternity hospital. Eur J Obstet Gynecol Reprod Biol. 2020; 250:86–92. PMID: 32413667.

21. Kim MK, Lee SM, Bae SH, Kim HJ, Lim NG, Yoon SJ, et al. Socioeconomic status can affect pregnancy outcomes and complications, even with a universal healthcare system. Int J Equity Health. 2018; 17(1):2. PMID: 29304810.

22. Shin J, Lee SG, Park EC, Nam JY. Socioeconomic status and successful delivery after an infertility diagnosis: a nationwide health insurance cohort study in Korea conducted from 2005 to 2013. J Korean Med Sci. 2020; 35(39):e341. PMID: 33045770.

23. Henriksen TB, Savitz DA, Hedegaard M, Secher NJ. Employment during pregnancy in relation to risk factors and pregnancy outcome. Br J Obstet Gynaecol. 1994; 101(10):858–865. PMID: 7999687.

24. Lemasters GK, Pinney SM. Employment status as a confounder when assessing occupational exposures and spontaneous abortion. J Clin Epidemiol. 1989; 42(10):975–981. PMID: 2809655.

25. Kim CB, Choe SA, Kim T, Kim MH, Ryu J, Oh JW, et al. Risk of adverse pregnancy outcomes by maternal occupational status: a national population-based study in South Korea. J Occup Health. 2023; 65(1):e12380. PMID: 36694993.