Infertility Insurance Mandates and Maternal Mortality

While maternal mortality rates fell overall and for high-income countries over recent decades, they increased in the United States over the same period. This paper considers the extent to which mandated insurance coverage of infertility treatment in the United States contributed to the increase in maternal mortality. Infertility treatment consists of medical technologies that help women and couples with fertility problems conceive a child using such methods as in vitro fertilization (IVF). While the development of these technologies has benefited many women, a number of women remain unable to use these treatments due to their high prices. However, beginning in 1977 and continuing through 2001, 15 states mandated insurance coverage for infertility treatment in some form.

Extensive work using difference-in-differences approaches has found the infertility insurance mandates were associated with increases in the use of infertility treatment and increases in births and multiple births. Less work has explored how these mandates affected maternal outcomes. This paper considers how mandated insurance coverage of infertility treatment affected maternal mortality. The mandates could have affected maternal mortality in several ways. To the extent that the mandates increase the number of women giving birth, they will increase the number of women dying as a result of pregnancy- and birth-related causes. From this channel, the effect on the overall maternal mortality rate will be determined by whether these pregnancies are more or less at risk of leading to maternal mortality than the average birth. The mandates may also have an effect through changing the choice of procedures of differing risk.

To consider effects of the mandates on maternal mortality, analyses apply difference-in-differences methods using 1981-1998 Vital Statistics data on births and maternal mortality for women ages 35-49. The paper exploits variation by state and over time in mandated health insurance coverage of infertility treatment to examine the effect of the mandates on maternal mortality. To this end, I examine the effect of the mandates on the birth rate (births per population), the death rate (deaths per population), and the maternal mortality rate (deaths per births). I examine these outcomes separately by race. I further examine the maternal mortality rate by detailed cause of death and consider heterogeneity in state mandates.

Results suggest that, rather than increasing maternal mortality, the mandates were associated with a decrease in the maternal mortality rate for White women ages 35-49. The results of this analysis are important for quantifying effects of existing policies mandating health insurance coverage of infertility treatment as well as considering potential effects of future policies. These results also add to the literature on maternal mortality. The results of this analysis do not suggest the increase in maternal mortality observed over recent decades is driven by mandated health insurance coverage of infertility treatment.