Poverty and Social Disadvantage in Women and Men and Fertility Outcomes

Poverty and social disadvantage are associated with increased risks of pregnancy complications. It is not known whether poverty and social disadvantage are associated with subfertility and miscarriage risks.

To assess whether poverty and markers of social disadvantage, including low educational level and household income among both women and men, are associated with subfertility and miscarriage risks.

This population-based prospective cohort study, which was conducted in an urban setting in Rotterdam, the Netherlands, between August 9, 2017, and July 1, 2021, included women and their partners from the preconception period onward with follow-up until birth. The date of analysis was July 8, 2025.

Poverty, defined as a household income of less than €3000 per month and experiencing financial difficulties; educational level; and household income.

The main outcomes were fecundability, defined as the per-month probability of conceiving; subfertility, defined as a time to pregnancy or the duration of actively pursuing pregnancy of more than 12 months or use of assisted reproductive technology; and miscarriage, defined as pregnancy loss before 22 weeks' gestation. Data were analyzed using Cox proportional hazards regression and modified Poisson regression models.

Among 3604 women (median age, 31.2 [IQR, 28.5-34.3] years) and 2557 male partners (median age, 33.2 [IQR, 30.0-36.6] years), the time-to-pregnancy study population consisted of 2851 episodes among women (median age, 31.5 [IQR, 29.1-34.4] years) and 2830 episodes among men (median age, 33.3 [IQR, 30.4-36.7] years). The miscarriage study population consisted of 2515 episodes among women (median age, 31.3 [IQR, 28.8-34.1] years) and 2498 episodes among men (median age, 33.3 [IQR, 30.1-36.5] years). Among women, the median time to pregnancy was 3.5 months (95% range [2.5%-97.5%], 0-67.8 months); in total, 974 episodes (34.6%) were subfertile, and 297 pregnancy episodes (11.8%) led to a miscarriage. Subanalyses were based on 2103 to 2805 episodes among women. Poverty was associated with lower fecundability (confounder model fecundability ratio [FR], 0.61 [95% CI, 0.51-0.72]). Also, as compared with high educational level, low educational level among women (FR, 0.61 [95% CI, 0.50-0.74]) and men (FR, 0.72 [95% CI, 0.62-0.85]) was associated with lower fecundability. As compared with a household income of €6000 or more per month, a household income of less than €3000 per month was associated with lower fecundability (FR, 0.59 [95% CI, 0.51-0.68]). The effect estimates of subfertility were in line with those for fecundability; for example, poverty was associated with increased subfertility risk (32.5% vs 50.3%; relative risk, 1.37 [95% CI, 1.16-1.62]). These associations were only partly explained by demographic and lifestyle factors. Poverty and markers of social disadvantage were not associated with miscarriage risk.

The findings of this cohort study suggest that poverty and social disadvantage, characterized by low educational level and household income among both women and men, were associated with lower fecundability and increased risks of subfertility but not with miscarriage risk. Further studies are needed to identify the underlying and explanatory mechanisms associated with fertility outcomes and the potential for novel public health strategies for couples desiring pregnancy.