(The) impact of health insurance coverage for assisted reproductive technology on multiple pregnancy and birth in South Korea
저자
발행사항
[Seoul] : Graduate School, Yonsei University, 2023
학위논문사항
학위논문(박사) -- Graduate School, Yonsei University Department of Public Health 2023.8
발행연도
2023
작성언어
영어
주제어
발행국(도시)
서울
기타서명
난임 보조생식술 건강보험 급여화가 다태아 임신 및 출산에 미치는 영향
형태사항
viii, 89장 : 삽화 ; 26 cm
일반주기명
지도교수: Eun-cheol Park
UCI식별코드
I804:11046-000000549930
소장기관
ABSTRACT
The Impact of Health Insurance Coverage for Assisted Reproductive Technology on Multiple Pregnancy and Birth in South Korea
Background: Since 2002, Korea has experienced an ultra-low birth rate with a total fertility rate <1.3. Recognizing the problem of low fertility due to late marriage and low birth rate as a societal responsibility rather than an individual responsibility, the government initiated a large-scale support project for infertile couples with low income in 2006, in which the government subsidized part of the cost of assisted reproductive technology in response to the low birth rate. Since October 2017, health insurance has been used to provide universal cost support regardless of income level, and infertility treatment is being expanded to all couples with infertility who desire children. The number of births due to the national assisted reproductive technology (ART) support program for couples with infertility has also increased. In this background, this study aimed to evaluate the effect of ART health insurance mandate on multiple pregnancies and births in Korea.
Methods: In this population-based cohort study, we used two data sources: Data from the National Health Insurance Service (NHIS)-delivery cohort database (July 2015 to December 2019) were used in the individual-level analysis, and publicly released data from the Statistics Korea were also used in the aggregate-level analysis. A total of 1,474,484 individuals were included in the study after excluding individuals with no birth records at Korean medical institutions and those with missing data. Since the NHIS had begun covering ART on October 1, 2017, and the last follow-up date for the data was December 31, 2019, we determined the follow-up period before and after the intervention to be 27 months each (pre-intervention period: July 2015 to September 2017; post-intervention period: October 2017 to December 2019). Multiple pregnancies and multiple births were identified by diagnosis codes according to the International Classification of Diseases, 10th revision. Total births were defined as the total number of babies born to each pregnant woman during the follow-up period. In aggregate-level analysis, an average of 12,524,214 women of childbearing age per month, and an average of 29,701 live births per month were included in the analysis. An interrupted time series with segmented regression was performed to analyze the time trend and its change in outcomes.
Results: After covering ART treatment, the likelihood of multiple pregnancies and multiple births was estimated to increase by 0.7% (p<.0001) and 1.2% (p<.0001), compared to before coverage. The probability of an increase in the number of total births per pregnant woman after the intervention was estimated to be 0.5% (p<.0001). The relatively high-income class above the median income showed a decreasing trend in multiple births and total births before the intervention, but after the intervention, it turned to a significant increase. On the other hand, the implementation of ART coverage policy had no significant impact on the marriage and pregnancy rates. However, it did affect multiple pregnancy and multiple birth rates, which increased by 1.0% (p=0.0001) and 1.4% (p<.0001), respectively, compared to the pre-intervention period. Although the effect of covering ART treatment on the total birth rate was not confirmed, a slightly slower decline was observed after the intervention (Exp(β1)=0.993, p<0.0001, Exp(β1+β3)=0.996, p= 0.012).
Conclusions: This population-based cohort study found that the possibility of multiple pregnancies and births in Korea significantly increased after the implementation of an ART health insurance coverage policy. This policy increased the fertility rate of couples who wanted to have children, but did not contribute to raising the overall fertility rate. Nonetheless, our findings suggest that ART health insurance coverage policies that can support infertile couples should be further developed to urgently solve the problem of Korea’s low fertility rate.
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