Cultural determinants influence assisted reproduction usage in Europe more than economic and demographic factors

The use of ART varies considerably across countries in Europe (Calhaz-Jorge et al., 2016, Präg and Mills, 2017). The most recent release of the registers of the European IVF-Monitoring Consortium (EIM) for the European Society of Human Reproduction and Embryology (ESHRE) (Calhaz-Jorge et al., 2016) reveals that the number of ART treatment cycles in 2012 ranged between 1457 per million women between the ages of 15 and 44 in Moldova compared to 14 431 per million women in the same age range in Denmark. The reasons for these differences, however, are not yet fully understood.

The economic development of countries has been previously considered as a main driving factor, but cannot explain the vast differences between countries. While richer countries have a somewhat higher prevalence of ART use, the relationship is far from perfect, with many poorer countries in Europe having high levels of ART usage. For instance, the Czech Republic reported 10 473 cycles per million women of reproductive age in 2012 but ranks low (51st) in national wealth as measured by purchasing power parity GDP. The Czech Republic has an ART treatment level that is close to the comparatively wealthier Denmark (ranked 37th), whereas high-income nations such as Italy (ranked eighth) and the United Kingdom (ranked fifth) reported only 5480 and 4918 cycles per million women of reproductive age, respectively (World Bank, 2011).

Existing research points to other economic, regulatory and demographic factors underlying country differences in ART uptake. Chambers et al. (2014) argued that it is not only country wealth, but rather the consumer affordability of treatment that drives the country differences in ART usage. Countries where ART treatments are more affordable due to insurance mandates or public subsidies have higher ART usage, suggesting that a cost cut of 10 percentage points of the average disposable income in a country predicts a 32% increase in ART utilization. With respect to ART regulation, Berg Brigham et al. (2013) showed that European countries with more liberal social eligibility regulations registered higher levels of ART usage. Kocourkova et al. (2014) illustrate that country differences in ART usage are related to fertility postponement. The greater the extent of postponement of first birth in a country, the higher demand for ART treatments. These studies have identified important societal drivers of cross-country differences in ART utilization.

Large-scale cross-national empirical research on cultural and normative factors shaping ART usage are rare, with some studies showing that cultural factors such as social norms and religion may be important predictors of ART usage (Benagiano, 2008; Adamson, 2009). Billari et al. (2011) reported that country differences in social age deadlines for childbearing, such as beliefs about having a child too early or too late, were predictive of differences in ART availability in European countries.

This study examines ART utilization data from 35 European countries and examines the extent to which financial, demographic, and cultural determinants explain the vast cross-national differences in ART usage and treatments in Europe. We replicate the well-known correlation of country wealth and ART treatments. In addition, we show how demographic factors such as fertility postponement are related to ART usage. There is a well-established link between women's higher educational attainment and postponement (Mills et al., 2011, Balbo et al., 2013), with the proportion of higher educated women also varying across nations. We therefore focus on the group of women most likely to postpone childbearing, namely mid-aged, highly educated women. We then take regulatory aspects of ART in the countries under study into account (Präg and Mills, 2015) and make use of survey data to understand country differences in the moral and normative cultural acceptance towards ART and how religious composition of countries is related to ART usage.