Infertility and Seeking Medical Help to Have a Child Vary Across Migrant Origin Groups in Germany

Milewski, Nadja; Passe -Wi ig, Jasmin; Buja d, Ma in
A icle — Published Ve sion
In e ili y and Seeking Medical Help o Ha e a Child Va y
Ac oss Mig an O igin G oups in Ge many
Popula ion Resea ch and Policy Re iew
P o ided in Coope a ion wi h:
Sp inge Na u e
Sugges ed Ci a ion: Milewski, Nadja; Passe -Wi ig, Jasmin; Buja d, Ma in (2025) : In e ili y and
Seeking Medical Help o Ha e a Child Va y Ac oss Mig an O igin G oups in Ge many, Popula ion
Resea ch and Policy Re iew, ISSN 1573-7829, Sp inge Ne he lands, Do d ech , Vol. 44, Iss. 2,
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ORIGINAL RESEARCH
In e ili y andSeeking Medical Help oHa e aChild Va y
Ac oss Mig an O igin G oups inGe many
NadjaMilewski1 · JasminPasse ‑Wi ig1 · Ma inBuja d1
Recei ed: 4 Ma ch 2024 / Accep ed: 12 No embe 2024 / Published online: 29 Ma ch 2025
© The Au ho (s) 2025
Abs ac
This s udy in es iga es he ex en o which immig an s in Ge many a e aced wi h
in e ili y, and i examines hei use o ep oduc i e heal h-ca e se ices. P e ious
esea ch on mig an e ili y cen e ed mos ly on he highe e ili y a es o immi-
g an s and hei adap a ion p ocesses, bu has la gely neglec ed in e ili y. A he
same ime, esea ch on in e ili y in he Eu opean low- e ili y con ex has ocused
almos exclusi ely on non-mig an popula ions. Ou esul s indica e highe in e ili y
and lowe seeking o medical help among mig an s as compa ed wi h non-mig an s.
Howe e , he e is subs an ial he e ogenei y be ween di e en mig an g oups: Fi s -
gene a ion mig an s show highe isks o in e ili y and lowe use o medical help o
ge p egnan . The s udy also shows di e ences acco ding o (pa en s’) egions o o i-
gin: Pe sons om Russia, Cen al Asia, and he Middle Eas (including Tu key) ha e
a highe isk o pe cei ing in e ili y o unce ain y abou i han o he Eu opean
o igin g oups. Those om Russia and Cen al Asia ha e he lowes use o medical
help-seeking. These g oup di e ences canno be explained by socioeconomic ac-
o s. Ou esul s sugges ha ce ain immig an g oups—despi e ha ing on a e age a
highe numbe o child en— ace no able ep oduc i e disad an ages, which dese e
u he a en ion in esea ch on mig an e ili y and assis ed ep oduc ion in gene al.
Keywo ds In e ili y· Sub ecundi y· Mig a ion· Medically assis ed ep oduc ion
(MAR)· Assis ed ep oduc i e echnology (ART)· Rep oduc i e heal h· S a i ied
ep oduc ion· Ge many
* Nadja Milewski
nadja.milew[email p o ec ed]
Jasmin Passe -Wi ig
[email p o ec ed]
Ma in Buja d
Ma [email p o ec ed]
1 Fede al Ins i u e o Popula ion Resea ch (BiB), F ied ich-Ebe -Allee 4, 65185Wiesbaden,
Ge many
N.Milewski e al.
25 Page 2 o 38
In oduc ion
This s udy in es iga es he e ogenei y in in e ili y pe cep ions and help-seeking
beha io by compa ing immig an s wi h he na i e non-mig an popula ion in
Ge many. In cu en demog aphic esea ch he e is g owing in e es in in e ili y
(Ca son & Kallen, 2021; Lazza i e al., 2022; McQuillan e al., 2022), seeking
medical help o ge p egnan (Doma e al., 2012; G eil e al., 2010; Passe -Wi ig
& G eil, 2021), and he apidly g owing sec o o ep oduc i e medicine (Adam-
son e al., 2018; Aleixand e-Bena en e al., 2015; C aw o d & Ledge , 2019) in
he Global No h. This is because egions like Eu ope a e cha ac e ized by e il-
i y pos ponemen , and olde age is one o he mos impo an non-modi iable isk
ac o s o in e ili y (Dunson e al., 2002; E e s, 2002). Howe e , p e ious quan-
i a i e s udies ha e a ely included immig an o e hnic mino i ies in Eu ope,
which is no ewo hy, as he p opo ion o mig an s and hei bi h numbe s is
signi ican and inc easing ac oss Eu ope (Baga os, 2019; Passe -Wi ig & G eil,
2021; Sobo ka, 2008).
We a gue ha in e ili y is an impo an aspec o conside in esea ch on
mig an popula ions, because i has implica ions o hei li e cou se and amily
s uc u e, bu also o di e en demog aphic de elopmen s o social g oups. In
addi ion, knowledge o how in e ili y a ies ac oss di e en mig an g oups can
also p o ide impo an insigh s in o he p ocesses o adap a ion wi hin mig an
popula ions, o example by looking a mig an gene a ion o g oups o o igin
coun ies (Wilson, 2019). P e ious quan i a i e s udies on mig an e ili y in
Eu ope mos ly in es iga ed he e ili y adap a ion p ocesses o immig an s om
high(e )- e ili y con ex s. They gene ally ound ha e ili y le els o immig an
g oups a e on a e age highe han hose o na i es and ha hey decline in sub-
sequen gene a ions (Kulu e al., 2019; Milewski, 2010). The pe cei ed “hype -
e ili y” o a leas some immig an g oups may ha e con ibu ed o mig a-
ion esea che s neglec ing e ili y ba ie s in immig an g oups (A kin, 2009;
Haug & Milewski, 2018; Inho n & an Balen, 2002). Howe e , he composi ion
o mig an g oups in Eu ope is changing, i.e. mig an s a e mo e o en coming
om coun ies wi h low and la e e ili y in Eas e n Eu ope and La in Ame ica
(González-Fe e e  al., 2017), o om coun ies wi h apidly changing e il-
i y pa e ns, e.g. Tu key (Bayka a-K umme & Milewski, 2017). Mo e ecen ly,
mig an g oups, such as e ugees, ha e a ac ed schola ly a en ion (Saa ela &
Wilson, 2022). These pape s poin o declining e ili y in pa icula ly ulne able
g oups—howe e , he ole o in e ili y s ill is an open ques ion. Ou s udy he e-
o e complemen s esea ch on mig an e ili y by looking a in e ili y and he
seeking o medical help o ha e a child.
A be e unde s anding o in e ili y among mig an popula ions also p o ides
impo an in o ma ion abou he well-being, heal h s a us, and access o ep o-
duc i e heal h ca e o hese popula ions. P e ious empi ical esul s on a ious
aspec s o mig an heal h p oduced mixed esul s, sugges ing ha selec ion p o-
cesses accompanying emig a ion, i.e. he heal hy mig an e ec , and selec ion
In e ili y andSeeking Medical Help oHa e aChild Va y Ac oss… Page 3 o 38 25
associa ed wi h emig a ion, i.e. he salmon bias e ec , play a ole (Razum e al.,
2000). Compa a i ely ew demog aphic s udies ha e looked in o pe ina al heal h
o bi h ou comes in mig an popula ions (Jua ez e al., 2019; Milewski & Pe e s,
2014; Väisänen e  al., 2022). Only ecen ly, a emp s ha e been made o con-
side he ole o women’s heal h in s udies o mig an e ili y (Alde o i & T ap-
polini, 2022), o o include mig an s a us in analyses o in e ili y pe cep ions
(Passe -Wi ig e al., 2020) and o medical help-seeking o in e ili y (Köppen
e al., 2021). Despi e hese ew excep ions, esea ch on mig an in e ili y ca e in
Eu ope is sca ce. I comp ises quali a i e s udies, mos ly pa ien samples d awn
om clien s using ep oduc i e heal h-ca e se ices (Culley e al., 2006)—ye , i
is no clea whe he he p e alence o in e ili y and medical help-seeking o ha e
a child is simila o ha o he majo i y popula ion, and how much a ia ion he e
is be ween di e en mig an g oups in Eu ope.
In he US, Colen (1986) coined he e ms a i ied ep oduc ion o desc ibe how
ep oduc ion is s uc u ed ac oss social and cul u al bounda ies. The implica ion
is ha policies and s uc u es empowe p i ileged—Whi e, non-mig an women
belonging o he majo i y g oup—and disempowe less p i ileged—mig an —
women h oughou hei li e cou ses. The ield o medically assis ed ep oduc ion
(MAR) is s a i ied, as ba ie s based on class and ace/e hnici y pe sis (Inho n,
2018). Recen sys ema ic li e a u e e iews on ep oduc i e endoc inology and
in e ili y ha e only analyzed s udies om he US (Ch is e al., 2022; Jackson-Bey
e  al., 2021; Me kison e  al., 2023); hey p edominan ly indica e ha e hnic and
acial mino i y g oups a e disad an aged in ep oduc i e ca e and access o in e -
ili y ea men . I is unclea whe he such indings can be gene alized o he Eu o-
pean con ex , gi en he di e ences in immig an and e hnic mino i y popula ions
and heal h-ca e sys ems (Calhaz-Jo ge e al., 2020; Passe -Wi ig & Buja d, 2021;
P äg & Mills, 2017).
Agains his backg ound, we pose he ollowing esea ch ques ions: Fi s , wha
a e he pa e ns and de e minan s o in e ili y among mig an g oups in Ge many?
Second, wha a e he pa e ns and co ela es o hei use o medically assis ed ep o-
duc ion? Fo bo h ques ions, we compa e mig an s wi h he non-mig an majo i y
popula ion and examine di e ences among a ious mig an g oups. Fo he la e ,
we pay pa icula a en ion o he ole o he mig an gene a ion and he mig an s’
egion o o igin.
Ou s udy pools da a om 12 wa es o he Ge man amily panel s udy pai am
(Huinink e al., 2011) o in es iga e sel -pe cei ed in e ili y o indi iduals (i sin-
gle) o couples. Impo an ly, we include unce ain y in he esponse beha io , i.e.
he answe ca ego y o “I don’ know” o accoun o he sensi i i y o he in e -
ili y ques ion and cul u al di e ences in esponse beha io . We go beyond exis -
ing esea ch by s udying sel -pe cei ed in e ili y and help-seeking beha io in he
same sample. The e o e, we can ela e he po en ial need o he usage o MAR. This
allows us o d aw conclusions abou he ex en o which di e ences in medical help-
seeking be ween mig an s and non-mig an s may be ela ed o di e en needs and/o
o, e.g. ins i u ional ba ie s (Jackson-Bey e al., 2021).
N.Milewski e al.
25 Page 4 o 38
Backg ound
Coun y Con ex
Ge many makes an in e es ing case o his s udy o in e ili y and medical help-
seeking due o he inc easing mul i-e hnici y o i s popula ion. Ge many has been
one o he main des ina ions o mig an s in Wes e n Eu ope o se e al decades.
The e o e, he p opo ion o immig an s, including hei descendan s, has been
ising s eadily and accoun ed o abou 30% o he popula ion in 2023. Among
he younge coho s, he age g oup o 20 o 45yea s, who a e o ep oduc i e age
and po en ial use s o MAR, abou 37% a e immig an s, including hei descend-
an s ( his g oup is made up o abou 15% o pe sons wi h Ge man ci izenship
and abou 22% o pe sons wi h (exclusi ely) o eign ci izenship) (Des a is, 2024).
Since he end o Wo ld Wa II in 1945, immig an s came o Ge many o a ious
easons and om a a ie y o egions o o igin. Immig an g oups include, among
o he s, labo mig an s om sou he n Eu opean coun ies and Tu key since he
1960s, and since he 1990s, inc easingly om Eas e n and Sou h-eas e n Eu o-
pean coun ies. In addi ion, immig an g oups include e hnic Ge mans mainly
om Eas e n Eu ope (e.g., om o me So ie coun ies) and e ugees om he
Balkan coun ies ( ollowing he wa s in he o me Yugosla ia), I aq o Sy ia. In
2023, he coun ies o o igin o mig an s and hei descendan s in Ge many we e
di ided in o 28% Nea and Middle Eas (including Tu key), abou 5% Kazakh-
s an, abou 5% Russia, abou 15% Balkan coun ies, abou 29% No h, Wes , Cen-
al, Sou h, Sou h-Eas Eu ope, and abou 17% o he s. Socioeconomic di e ences,
such as sex a io, educa ion, and household income, a y widely be ween hese
mig an g oups, e.g. he sha e o low educa ion is highe han among na i es in
Kazakhs an and he Balkan coun ies and highes in he Nea and Middle Eas
(Des a is, 2024).
Ano he eason why Ge many is a good case s udy is i s long-s anding low e -
ili y a e and he sha p ise in he mean age o childbea ing. Al hough he e has
been a sligh inc ease in he o al e ili y a e (TFR) in ecen yea s un il 2021
(Buja d & Ande sson, 2024), i s ill emains well below he popula ion eplace-
men le el o 2.1 bi hs pe woman. In addi ion, a o e 20%, Ge many has a
high a e o childlessness, and simila o o he coun ies in he Global No h, he
causes o his a e a om being ully unde s ood. One o he easons lies in
he inc easing age a which women and men a e ha ing child en, which is a c u-
cial isk ac o o in e ili y (Dunson e al., 2002; E e s, 2002). Acco ding o he
medical de ini ion, people a e conside ed in e ile a e one yea o mo e o egu-
la unp o ec ed in e cou se wi hou ge ing p egnan (Zege s-Hochschild e  al.,
2017).
O e all, he p e alence o sel -pe cei ed in e ili y in Ge many is cu en ly
es ima ed a a ound 5–6% o bo h men and women (Passe -Wi ig e al., 2020).
In e ili y inc eases wi h age, e lec ing he age- ela ed inc ease in a ious biolog-
ical e ili y p oblems (ESHRE, 2005). In pa allel wi h he ongoing demog aphic
end o e ili y pos ponemen , he use o MAR is inc easing in Eu ope. MAR

In e ili y andSeeking Medical Help oHa e aChild Va y Ac oss… Page 5 o 38 25
is a g owing heal h-ca e sec o in Ge many and widely a ailable (DIR, 2021),
bu ea men a es a e ela i ely low compa ed o o he Eu opean coun ies (De
Gey e e al., 2020; P äg & Mills, 2017). One eason o his may be ha access
o ea men in Ge many is a he es ic i e and no e y inclusi e. Cu en ly,
public heal h-ca e insu ance only eimbu ses ma ied he e osexual couples and
ypically co e s 50% o ea men cos s o a maximum o h ee IVF (in- i o
e iliza ion) cycles. As a esul , he use and iming o MAR is highly dependen
on he economic si ua ion o he pe son o couple (Köppen e al., 2021; Passe -
Wi ig, 2017).
Mig an s, E hnic Di e si y, andIn e ili y
In Ge many, as in o he Eu opean coun ies, he he e ogenei y o he popula ion has
inc eased as a esul o con inuing and changing immig a ion and di e en demo-
g aphic beha io o immig an and majo i y popula ions. Fo some ime now, schol-
a s ha e acknowledged ha mig an s a e highly he e ogeneous—wha has been
e med as “supe di e si y” (Ve o ec, 2007). The no ion o wi hin-mig an he -
e ogenei y is ecei ing inc easing a en ion in esea ch on he demog aphic beha -
io o mig an s, such as esea ch on e ili y (E man, 2022; Milewski & Adse à,
2023; Wilson, 2019) and esea ch on ep oduc i e heal h (Väisänen e  al., 2022).
Acknowledging his he e ogenei y helps o mo e beyond a bina y, simplis ic dis-
inc ion be ween immig an s and non-mig an s, o na i es. Key cha ac e is ics ha
accoun o mig an he e ogenei y a e mig an gene a ion and egion o o igin. So
a , gende di e ences and dyadic app oaches ha conside bo h pa ne s in a couple
ha e ecei ed only li le a en ion (Lazza i e al., 2022).
S udies on mig an e ili y in Eu ope look almos exclusi ely a women and ha e
mainly ocused on how mig a ion impac s he subsequen li e cou se o mig an s
and hei descendan s, i.e. bi h ansi ions, and how e ili y a ies among mig an s
acco ding o hei o igin and des ina ion con ex s (Adse à & Fe e , 2015; Kulu
e al., 2019; Milewski & Adse à, 2023). Empi ical s udies on he e ili y o immi-
g an s in Eu ope p o ide suppo o he hypo hesis o mig an selec ion, e.g. in he
case o ma iage mig an s, which e e s o i s -gene a ion mig an s who mo e o
ma y a spouse ab oad, and who a e o en subjec o special immig a ion egula-
ions. A he same ime, he in luence o socializa ion in high(e ) e ili y con ex s,
which pe sis s long a e mig a ion, p o es o be signi ican . Immig an s o en ha e
ea lie childbea ing schedules, o e all ha e highe e ili y han hei non-mig an
coun e pa s a des ina ion, and childlessness is a he low among immig an s.
Mig an e ili y le els ypically decline wi h inc easing leng h o s ay and in he
subsequen mig an gene a ion; while age a childbea ing ises—which is usually
in e p e ed as a esul o adap a ion p ocesses and mig an child en’s adjus men o
he low(e ) e ili y con ex s a des ina ion (o e iew Kulu e al., 2019; o Ge many:
Milewski, 2007, 2010; K ap & Wol , 2015; Wol , 2016). A he same ime, cul u -
ally di e ing a i udes ega ding he ele ance o ma iage o childbea ing (Liu &
Kulu, 2023), di e ences in gende - ole a i udes, in pa icula owa ds mo he hood
(Haug & Milewski, 2018), pe sis o e gene a ions be ween mino i y and majo i y
N.Milewski e al.
25 Page 6 o 38
g oups. These cul u al cha ac e is ics, along wi h socioeconomic ac o s, a e condu-
ci e o ( ela i ely) ea lie and highe e ili y schedules (Milewski, 2010).
In addi ion o selec ion, adap a ion,and socializa ion, ano he mechanism link-
ing mig a ion and e ili y is dis up ion. Based on he assump ions ha in e na-
ional mig a ion is a s ess ul p ocess (Sluzki, 1979) and ha mig an s may expe i-
ence p ocesses o ma ginaliza ion, he dis up ion hypo hesis p edic s lowe e ili y
among mig an s compa ed o non-mig an s. Howe e , he e is li le e idence o sup-
po he dis up ion hypo hesis. On he one hand, his may be ela ed o he ac ha
mos empi ical s udies o da e ha e examined labo o amily mig an s (Mussino &
S ozza, 2012). Recen ly, a ew s udies ha e looked a g oups, which may expe i-
ence mo e nega i e impac s o mig a ion on ma iage and pa ne ship. Re ugees in
Finland (in he 1940s) we e ound o ha e lowe e ili y (Saa ela & Wilson, 2022).
On he o he hand, mos empi ical s udies ocus on immig an s in coun ies wi h e -
ili y below o close- o- eplacemen le el. I majo i y popula ions ha e lowes -low
e ili y, i is i ually impossible o mig an s o all below ha le el.
We no iced ha he empi ical s udies on mig an e ili y (including ou own
ones) in e p e declining e ili y le els as e idence o adap a ion p ocesses in
mig an popula ions. This in e p e a ion is based on he implici assump ion ha he
di e ences be ween he g oups o hei changes o e ime a e he esul o olun a y
decisions o ha e ewe child en. Howe e , p e ious esea ch has no sys ema ically
compa ed he indi idual e ili y in en ions o mig an s wi h hei e ili y ou comes
and he causes o any gap, and whe he any gap di e s om he co esponding gap
among non-mig an s. This aises he ques ion o he ex en o which any e ili y
decline and any gap be ween in en ions and e ili y a e due o delibe a e choices, o
e ili y ba ie s such as in e ili y, o o a combina ion o he wo.
In e ili y is a ba ie o ep oduc ion ha is also ela ed o heal h. Recen ly, poo
gene al and men al heal h among mig an women and men has been shown o educe
e ili y in en ions (Alde o i & T appolini, 2022). Howe e , compa a i ely ew s ud-
ies ha e looked a ep oduc i e ba ie s, including in e ili y (Johnson e al., 2023) o
pe ina al heal h (Väisänen e al., 2022). This is pa icula ly impo an o mig an s, as
heal h is unequally dis ibu ed. The e is conside able e idence o sugges ha in e na-
ional mig an s, pa icula ly hose mo ing o wo k o educa ion, end o be posi i ely
selec ed o heal h— his is gene ally e e ed o as he heal hy mig an e ec (HME).
Any ini ial heal h bene i s o i s -gene a ion immig an s a e assumed o diminish
when immig an s s ay longe in he hos coun y. Such ad an ages also dec ease o e
mig an gene a ions. The cause o his p ocess is a ibu ed o inc easing simila i ies
be ween mig an s and he espec i e hos popula ion in e ms o socioeconomic ac-
o s as well as li e s yle and s uc u al condi ions (Loi e al., 2021). The ini ial heal h
bene i o mig an s may disappea and hei heal h may de e io a e o a poin whe e i
is e en wo se han ha o he na i e popula ion. Some au ho s link he le elling o o
he HME o he expe ience o cumula i e disad an ages and disc imina ion in gene al
and he heal h-ca e sys em in pa icula , which in u n may inc ease he ulne abili y o
mig an s. Such disad an ages may pe sis o e gene a ions, i.e. when immig an g oups
de elop in o mino i ized g oups cha ac e ized by e hnici y, ace, o eligion (Bean &
Tienda, 1990; Ge onimus e al., 2006; Kulu e al., 2019). A he same ime, mino -
i y-g oup s a us and lowe socioeconomics a e associa ed wi h occupa ional haza ds,
In e ili y andSeeking Medical Help oHa e aChild Va y Ac oss… Page 7 o 38 25
en i onmen al isks and poo e housing condi ions, expe iences o disc imina ion, li e-
s yle isk ac o s, and poo e heal h ou comes (Bean & Tienda, 1990; Coleman, 1994;
Fone & Alba, 2008), and may con ibu e o a highe isk o in e ili y among mig an
and e hnic mino i y g oups (Jackson-Bey e al., 2021).
O e all, he empi ical e idence on ep oduc i e and pe ina al heal h suppo s he
hypo hesis o he heal hy mig an e ec , sugges ing ad an ages o i s -gene a ion
mig an s in pa icula . A he same ime, he e idence on ep oduc i e heal h highligh s
he impo ance o egion o o igin as a po en ial ma ke o di e ences. Fo ins ance,
wi h espec o p e- e m bi h (PTB)—a isk ac o o poo heal h and de elopmen
ou comes o he child— he e idence is mixed. Highe PTB isks we e ound in Fin-
land, bu mainly o women who immig a ed om low-income coun ies and no o
hose om high-income coun ies (Bas ola e al., 2020; Väisänen e al., 2022). In Swe-
den, esul s a ied be ween di e en g oups o o igin (Juá ez e al., 2019; Li e  al.,
2013) while in he UK, PTB isks we e lowe among immig an s (Opondo e al., 2020).
In his pape , we will use he e ms “ e ili y ad an age” o e e o lowe in e ili y
and “ e ili y disad an age” o e e o highe in e ili y. The ollowing main wo king
hypo heses guide ou empi ical s udy on pe cei ed in e ili y. We expec o ind a ia-
ion in pe cei ed in e ili y ac oss mig an gene a ions, wi h a mig an e ili y ad an-
age mainly in he i s gene a ion as compa ed o non-mig an s; he e ili y ad an age
may be smalle in he second gene a ion (H1A on gene a ional di e ences). Ou sec-
ond hypo hesis add esses he a ia ion by mig an s’ o igin-g oups: We expec a g ea e
e ili y ad an age o mig an s in o igin g oups ha show g ea e di e ence in e ili y
pa e ns when compa ed o Ge man na i es. Mig an s om coun ies wi h lowe ages
a bi h and highe e ili y le els, e.g. om he Middle Eas , may ha e lowe in e ili y
compa ed o Ge mans and compa ed o mig an s om coun ies wi h ageing e ili y
pa e ns, e.g. om o he Eu opean coun ies (H1B on o igin-g oup di e ences).
A hi d wo king hypo hesis e e s o he ole o mode a o s. We conside wo main
co ela es o in e ili y; i.e. age and gene al heal h. The mig an gene a ions and o igin
g oups exhibi di e ences in pa e ns o childbea ing age and heal h. On a e age, as
s a ed abo e, he lowe socioeconomic posi ions ha mig an s o en occupy in he hos
coun y may co ela e wi h a lowe age o childbea ing, highe a e age e ili y and
lowe a es o childlessness. An ea lie age o childbea ing may imply ha mig an s
a e less a ec ed by he pos ponemen pa e n, which inc eases he isk o age- ela ed
in e ili y. In e ili y is also ela ed o o he dimensions o heal h and li es yle. In ou
da a se , we can use he in o ma ion on sel - a ed heal h and assume ha be e heal h is
associa ed wi h lowe in e ili y. We expec ha con olling o heal h, age and pa en -
hood may educe in e ili y di e ences be ween mig an s and non-mig an s (H1C).
Mig an s, E hnic Di e si y, andSeeking Medical Help oGe P egnan
Medical in e ili y, o he pe cep ion o i , o en p omp s indi iduals o seek help
om ep oduc i e heal h-ca e se ices. This is he second ocus o ou s udy. Sys-
ema ic li e a u e e iews on ep oduc i e endoc inology and in e ili y (Ch is
e al., 2022; Jackson-Bey e al., 2021; Me kison e  al., 2023) indica e ha e hnic
and acial mino i y g oups in he US ace disad an ages in bo h ep oduc i e ca e
N.Milewski e al.
25 Page 8 o 38
and access o in e ili y ea men . In he Eu opean con ex , howe e , he e is limi ed
esea ch (Culley e al., 2006). Exis ing Eu opean s udies sugges b oad simila i ies
be ween mig an g oups in Eu ope and Black and La ino e hnic g oups in he US in
hei expe iences o p ejudice and disc imina ion in obs e ic p ac ice (in London
(Gü in-B oadben , 2009), o Ge many and England (Johnson & Bo de, 2009), in
The Ne he lands ( an Rooij & Ko ke , 2009), o Ge many (Vande linden, 2011)).
Inho n e al. (2009) also highligh ed immig an s om p edominan ly Muslim A ab
coun ies in he US, whose expe iences o disc imina ion and s igma ized pe cep-
ions o high e ili y mi o hose o Muslim immig an s in Eu ope, especially a e
9/11.
Ba ie s o accessing ep oduc i e heal h ca e and echnologies encompass a
wide ange o ac o s. These include p o ide - ela ed issues such as o e disc imi-
na ion, low cul u al compe ence, and delayed e e al o e ili y clinics. Financial
cons ain s and language ba ie s also pose signi ican p oblems (Geige , 2003;
Sei e e al., 2022). Ce ain aspec s may be a di ec esul o he disad an aged soci-
oeconomic condi ions aced by mig an o e hnic mino i y g oups, such as lowe
income and di icul ies in a o ding ea men . Indi ec ly, li e-s yle andheal h ac-
o s such as a highe isk o obesi y, which may be ci ed by p o ide s as a eason o
e using ca e, con ibu e o lowe u iliza ion o medical expe ise, lowe sa is ac ion
wi h ea men , and po en ially lowe success a es (Bu s, 2021; Galic e al., 2021;
Gü in-B oadben , 2009).
Some esea ch sugges s ha mig an s may be mo e likely han non-mig an s o
seek medical help o ge p egnan i hey pe cei e hemsel es o be acing in e ili y.
Fac o s ela ed o he mig an communi y, such as he in e gene a ional ansmis-
sion o cul u e and e ili y knowledge, may in luence clien s’ medical help-seeking
beha io (Culley & Hudson, 2009). Fo many mig an g oups, biological pa en hood
emains o u mos impo ance, pa icula ly in communi ies whe e childlessness is
uncommon, and he socie al epe cussions o in e ili y a e po en ially signi ican
(Ch is e al., 2022). In Ge many, immig an women we e ound o ha e lowe e il-
i y awa eness han non-mig an women, pa icula ly in e ms o knowledge ega d-
ing he age- ela ed e ili y decline (Milewski & Haug, 2022). Howe e , hey also
exp essed a g ea e willingness o use MAR when aced wi h concep ion di icul-
ies and showed mo e openness owa ds me hods such as egg dona ion and su o-
gacy which a e no allowed in Ge many. Fu he mo e, di e ences be ween mig an
g oups ha e been iden i ied: Fi s -gene a ion mig an s showed signi ican ly di e en
a i udes owa ds MAR use compa ed o non-mig an s, while esponses o second-
gene a ion mig an s we e mo e in line wi h hose o non-mig an s, indica ing ongo-
ing socioeconomic and cul u al assimila ion ac oss mig an gene a ions (Haug &
Milewski, 2018). No ably, mo e pe missi e a i udes and s onge in en ions o use
MAR we e obse ed, no only among women om coun ies wi h Muslim adi-
ions, such as Tu key, bu also among women om Eas e n Eu opean na ions such
as Poland, as well as hose wi h Ch is ian eligiosi y (Milewski & Haug, 2020).
Quan i a i e e idence on he ac ual beha io o seeking help o concei e among
mig an and e hnic mino i y g oups in Eu opean coun ies is bo h sca ce and incon-
clusi e. A non-pa ien s udy in Ge many ocused on immig an g oups, hei a i-
udes owa ds MAR and hei use o ea men . This s udy e ealed no signi ican
In e ili y andSeeking Medical Help oHa e aChild Va y Ac oss… Page 15 o 38 25
Resul s
Pe cep ion o In e ili y
Table1 shows he p opo ions o he o al sample, and o women and men, who pe -
cei ed in e ili y by mig an gene a ion and by coun y g oup o o igin. O e all, he
mean p e alence o pe cei ed in e ili y is abou 7.7%, wi h li le di e ence be ween
he sexes (8.0% o women and 7.5% o men). A o al o 4.8% o esponden s say
hey a e unsu e. Wi h 5.4%, men a e sligh ly mo e likely o s a e “don’ know” han
women (4.2%).
When we es ou wo king hypo hesis 1A, di e en ia ing by mig an gene a ion,
we ind signi ican di e ences: In he o al sample and among women and men,
he sha e o hose pe cei ing in e ili y is highe among i s -gene a ion mig an s
compa ed o non-mig an s and second-gene a ion mig an s. In he o al sample, pe -
cei ed in e ili y is abou 5 pe cen age poin s highe among i s -gene a ion mig an s
han among he o he wo g oupings. A simila pa e n is ound o he answe “don’
know”. 7% o he i s -gene a ion mig an s answe ed “don’ know”, compa ed o
5.3% o second-gene a ion mig an s and 4.3% o non-mig an s.
Tes ing ou wo king hypo hesis H1B, di e en ia ing by mig an s’ egion o o igin
also e eals signi ican di e ences be ween mig an g oupings. In o al, indi iduals
om he Balkan coun ies a e—a a ound 6%—by a he leas likely o pe cei e
in e ili y. The Balkan coun y g ouping also emains he leas likely o pe cei e
Table 1 Pe cei ed in e ili y by sex, mig an gene a ion and egion o o igin (%)
Calcula ions based on pai am wa es 1–12 (weigh ed da a). N o al = 12,777 pe sons wi h n = 58,802
obse a ions
Dk Don’ know, NWCSSE No h, Wes , Cen al, Sou h, Sou h-Eas Eu ope
*indica es signi ican a ia ion be ween he mig an s a us g oup a iables ega ding pe cei ed in e ili y
on 5% le el, based on Pea son chi-squa ed es s, es s a is ics calcula ed o ull sample only
To al sample Women Men
Fe ile In e ile Dk Fe ile In e ile Dk Fe ile In e ile Dk
Mig an gene a ion*
Non-mig an 88.8 6.9 4.3 89.2 7.1 3.7 88.5 6.6 4.9
Gen. 1 mig an 80.7 12.3 7.0 82.3 11.8 5.9 78.8 12.8 8.4
Gen. 2 mig an 87.1 7.7 5.3 87.4 7.8 4.8 86.7 7.5 5.8
Region o o igin*
Non-mig an 88.8 6.9 4.3 89.2 7.1 3.7 88.5 6.6 4.9
NWCSSE Eu ope 84.7 10.0 5.4 84.8 10.6 4.6 84.5 9.1 6.4
Balkan 89.1 6.0 4.9 89.9 4.4 5.7 88.1 8.1 3.8
Russia 77.9 13.7 8.4 77.1 16.0 6.9 79.2 10.1 10.7
Kazakhs an 81.9 10.6 7.6 83.8 10.0 6.2 79.9 11.2 9.0
Middle Eas 83.4 9.9 6.7 85.7 7.5 6.8 81.5 11.9 6.6
O he 84.0 9.9 6.1 87.3 8.8 3.9 80.5 11.1 8.4
O e all sha e 87.5 7.7 4.8 87.9 8.0 4.2 87.1 7.5 5.4
n 52,581 3779 2442 27,540 2131 1107 25,041 1648 1335

N.Milewski e al.
25 Page 16 o 38
in e ili y when di e en ia ing by sex. In con as , indi iduals om Russia a e—a
a ound 14%— he mos likely o pe cei e in e ili y in he whole sample, bu he e
a e some di e ences be ween he sexes. Women om Russia ha e—a a ound
16%— he highes p e alence o pe cei ed in e ili y. Among men, hose om
Kazakhs an and om he Middle Eas ha e he highes p opo ions o pe cei ed
in e ili y (11 o 12%), and hei p opo ions a e signi ican ly highe han hose o
women om he same egion. Among men om Russia, he sha e o hose pe cei -
ing in e ili y is also qui e high (abou 10%), bu much lowe han ha o women.
Addi ionally, we used he combined indica o o mig an gene a ion and egion
o o igin o he whole sample (no shown). This indica o sheds ligh on he egions
o o igin ha con ibu e mos o he inc eased isk o pe cei ed in e ili y among
i s -gene a ion mig an s. All egions o o igin excep he Balkans ha e highe pe -
cei ed in e ili y han non-mig an s, wi h mig an s om Russia ha ing by a he
highes sha e a almos 15%. O e all, second-gene a ion mig an s om mos egions
o o igin ha e a es o pe cei ed in e ili y ha a e no so di e en om hose o
non-mig an s ( ange: 3 o 9%). Mig an s om Eu ope ha e he highes p opo ion o
pe cei ed in e ili y (9%).
Fo he mul i a iable analyses, we p oceed in wo s eps o es ou wo king
hypo heses, i s using mig an gene a ion as he main independen a iable, and
second using he combined indica o o mig an gene a ion and egion o o igin.
Figu e1 shows he esul s o he mul i a iable analysis o mig an gene a ion using
AME ( he ull able o esul s can be ound in Table7 in he Appendix). The i s
ow in each ca ego y shows esul s om he baseline model (Models M1). Mode a-
o s and con ol a iables we e added in wo s eps (Models M2 o M3). The analyses
show ha i s -gene a ion mig an s a e 5.4 pe cen age poin s mo e likely o pe cei e
in e ili y han non-mig an s in he baseline model. Fi s -gene a ion mig an s a e
also 2.7 pe cen age poin s mo e likely o epo being unsu e han non-mig an s. In
con as , second-gene a ion mig an s do no di e om non-mig an s in hei p ob-
abili y o pe cei ing in e ili y.
The mig an disad an age o i s -gene a ion mig an s pe sis s when sex, pa -
en hood, heal h, and age a e in oduced o he model (Model M2). Thei in oduc-
ion a he esul s in a sligh inc ease in he p obabili y o pe cei ed in e ili y and a
la ge inc ease in he p obabili y o “don’ know”-answe s. Addi ionally, he inclu-
sion o ma i al s a us/pa ne ship and educa ion in Model M3 does no change he
associa ion be ween mig an gene a ion and pe cei ed in e ili y. Figu e2 comple-
men s he pic u e by highligh ing di e ences in egion o o igin wi hin mig an gen-
e a ions ( he ull able o esul s able can be ound in Table8 in he Appendix). In
he baseline model, i s -gene a ion mig an s om Russia a e 8 pe cen age poin s
mo e likely o pe cei e in e ili y han non-mig an s. Mig an s om he Balkan
coun ies a e he g oup wi h he smalles inc ease in he p obabili y o pe cei ed
in e ili y compa ed o non-mig an s. O e all, hese esul s emain s able when
mode a o s and con ols a e added o he model— hus, no suppo ing ou wo k-
ing hypo hesis H1C on he ole o he g oupings’ sociodemog aphics. By and la ge,
hemode a o s and con ols showed he e ec s known om he li e a u e: Pe sons,
who we e olde , childless and a ed hei heal h as poo we e mo e likely o pe cei e
in e ili y (Tables7 and 8 in he Appendix).
In e ili y andSeeking Medical Help oHa e aChild Va y Ac oss… Page 17 o 38 25
Hence, he esul s do no suppo ou wo king hypo hesis 1A; con a y o ou
assump ion, i s -gene a ion mig an s ha e a e ili y disad an age compa ed o
non-mig an s. Howe e , no such disad an ages we e ound o he second mig an
gene a ion. Ou esul s also con adic ou wo king hypo hesis 1B by showing ha
mig an s om coun ies whe e e ili y pa e ns a e cha ac e ized by a a he young
e ili y schedule ha e no lowe , bu highe a es o in e ili y and unce ain y—and
hus a e ili y disad an age—compa ed o non-mig an s.
Seeking Medical Help oHa e aChild
In ou second analysis, we look a seeking help o ha e a child in he sample o
hose who said ha hey we e ying o ha e a child. Table2 shows he p opo ion
o pe sons who indica ed any medical help-seeking. Tes ing ou wo king hypo h-
esis H2A, i.e. compa ing mig an gene a ions, we ound he lowes p opo ion
o help-seeke s among second-gene a ion mig an s and he highes among non-
mig an s, while i s -gene a ion mig an s we e in-be ween. This pa e n does no
align wi h hypo hesis H2A whe e we assumed ha second-gene a ion mig an s
would be close o non-mig an s han i s -gene a ion mig an s.
Non−mig an
Gen. 1
mig an
Gen. 2
mig an
−.1 −.05 0 .05 .1 .15 −.1 −.05 0 .05 .1 .15
Pe cei ed
in e ili y
Don’
know
M1 M2 M3
Fig. 1 Pe cei ed in e ili y, by sex and mig an gene a ion (AME). Calcula ions based on pai am wa es
1–12 (weigh ed da a), N o al = 12,777 pe sons wi h n = 58,802 obse a ions. AME a e age ma ginal
e ec s, NWCSSE No h, Wes , Cen al, Sou h, Sou h-Eas Eu ope. Mul inomial logi model; ull models
a e a ailable in Table7 (Appendix). Model M2 con ols o sex, age, pa en hood, and heal h. Model M3
addi ionally con ols o ma i al s a us/pa ne ship, educa ion,and wa e
N.Milewski e al.
25 Page 18 o 38
By egion o o igin— es ing ou hypo hesis H2B— a ia ion among mig an s
was less p onounced, excep o he e y he e ogeneous g oup o “o he ” egions.
The lowes sha es o help-seeking we e ound among esponden s om he Mid-
dle Eas , Russia, and Kazakhs an. These pa e ns a e no en i ely consis en wi h
wha would be expec ed om ou indings on pe cei ed in e ili y, whe e non-
mig an s would ha e lowe needs han i s -gene a ion mig an s, and people om
he Middle Eas , Russia and Kazakhs an would ha e a highe need as opposed o
o he g oupings. In ac , we ound he opposi e pa e n o use: he g oupings wi h
he highes in e ili y—i.e. po en ial need—ha e lowe ea men a es han hose
wi h lowe need. Thus, ou esul s do no suppo ou wo king hypo heses H2A
and H2B, bu a he indica e a mo e he e ogeneous pa e n.
Due o he ela i ely small sample size, we ocus on he compa ison be ween
mig an s and non-mig an s in he ollowing analyses, es ing he ole o mode a-
o s and con ols (wo king hypo hesis 2C). Fo he same eason, a simple indi-
ca o o seeking medical help s. no seeking medical help is applied in mos
desc ip i e and mul i a iable analyses.
Table 3 ela es he need o ea men — o he ex en ha his need can be
exp essed in e ms o pe cei ed in e ili y— o medical help-seeking. We compa e
Non−mig an
Gen. 1, NWCSSE Eu ope
Gen. 1, Balkan
Gen. 1, Russia
Gen. 1, Kazakhs an
Gen. 1, Middle Eas
Gen. 2, NWCSSE Eu ope
Gen. 2, Balkan
Gen. 2, Russia
Gen. 2, Kazakhs an
Gen. 2, Middle Eas
−.1 −.05 0 .05 .1 .15 −.1 −.05 0 .05 .1 .15
Pe cei ed
in e ili y
Don’
know
M1 M2 M3
Fig. 2 Pe cei ed in e ili y, by mig an gene a ion and mig an s’ egion o o igin (AME). Calcula ions
based on pai am wa es 1–12 (weigh ed da a), N o al = 12,777 pe sons wi h n = 58,802 obse a ions. AME
a e age ma ginal e ec s, NWCSSE No h, Wes , Cen al, Sou h, Sou h-Eas Eu ope. Mul inomial logi
model; ull models a e a ailable in Table8 (Appendix). Model M2 con ols o sex, age, pa en hood, and
heal h. Model M3 addi ionally con ols o ma i al s a us/pa ne ship, educa ion,and wa e. Residual ca -
ego ies “Gen. 1, o he ” and “Gen. 2, o he ” no shown in igu e
In e ili y andSeeking Medical Help oHa e aChild Va y Ac oss… Page 19 o 38 25
help-seeking a es be ween mig an s and non-mig an s by pe cei ed in e ili y
s a us. Gene ally, hose who pe cei e in e ili y a e abou wice as likely o ha e
sough medical help as hose who do no pe cei e in e ili y. Howe e , he help-
seeking a e among he la e is s ill signi ican , sugges ing ha sel -pe cei ed
in e ili y does no cap u e all he easons o seeking medical help. Help-seeking
a es a e highe among non-mig an s, whe he hey pe cei e in e ili y o no .
Howe e , he di e ence is much mo e p onounced when no e ili y p oblems a e
pe cei ed.
In a nex s ep, we compa e he sha e o help-seeke s o wo di e en ypes o
ea men be ween mig an s and non-mig an s. As Table 2 shows, 33% o non-
mig an s sough help o ha e a child, compa ed o abou 28% among i s -gene a ion
mig an s and 21% among second-gene a ion mig an s. When assessing he ype o
ea men  (no shown), mig an s a e less likely han non-mig an s o men ion he
amily doc o /gynecologis as he highes le el o ea men (abou 14% s. abou
23%), bu mig an s and non-mig an s a e simila ly likely o say ha hey ecei ed
ea men ypically p o ided in e ili y clinics (9.7% s. 9.6%). Impo an ly, i we
look only a hose who sough medical help o ge p egnan , mig an s a e mo e likely
o ha e ecei ed ea men a a e ili y clinic (mig an s: abou 40%; non-mig an s:
abou 29%).
Figu e 3 shows he esul s o he mul i a iable analysis, which a e consis en
wi h he desc ip i e indings (see Tables2 and 3). The e is a s able disad an age o
mig an s in seeking medical help o ha e a child: Thei p obabili y o seeking help is
abou 8 pe cen age poin s lowe han ha o non-mig an s. The nega i e associa ion
Table 2 Any medical help-
seeking, by mig an gene a ion
and egion o o igin (%)
Calcula ions based on pai am wa es 7–12 (weigh ed da a).
N o al = 1500 pe sons wi h n = 2,345 obse a ions
NWCSSE No h, Wes , Cen al, Sou h, Sou h-Eas Eu ope
*indica es signi ican a ia ion be ween he mig an s a us g oup
a iables ega ding medical help-seeking on 5% le el, based on
Pea son’s chi-squa ed es
Any medical help-seeking
No Yes
Mig an gene a ion*
Non-mig an 67.0 33.0
Gen. 1 mig an 72.3 27.7
Gen. 2 mig an 79.5 20.5
Region o o igin*
Non-mig an 67.0 33.0
Eu ope + Balkan 77.0 23.0
Russia/Kazakhs an 82.4 17.6
Middle Eas 82.8 17.2
O he 58.4 41.6
O e all sha e 69.8 30.3
n 1642 703
N.Milewski e al.
25 Page 20 o 38
be ween mig an s a us and help-seeking emains ela i ely s able in magni ude and
signi icance when mode a o s andcon ol a iables a e added— hus no suppo -
ing ou wo king hypo hesis H2C on he ole o he sociodemog aphic composi ion.
O he co a ia es, pa en hood and pe cep ion o in e ili y a e he s onges p edic-
o s—each educing he p obabili y o help-seeking by abou 20 pe cen age poin s.
As pa en hood is an impo an p edic o and mig an s a e mo e likely o ha e chil-
d en, also in ou sample, we also es ed whe he ha ing child en mode a es he asso-
cia ion be ween mig an s a us wi h medical help-seeking, bu ound no such e ec
(no shown).
O e all, he e ec s o he explana o y a iables a e in he di ec ions as known
om he li e a u e. Responden s in ou sample a e mo e likely o ha e sough medi-
cal help o ge p egnan i hey a e olde , childless, ma ied, ha e highe educa ion,
ha e a household income o 3500€ o mo e, and pe cei e hei heal h s a us as poo .
Robus ness andDa a Quali y
Ou es ima ed p e alence o pe cei ed in e ili y o 8.0% among women and 7.5%
among men is wi hin he ange o o he Eu opean s udies o sel - epo ed 12-mon h
in e ili y, bu a he lowe end o his ange (Cox e al., 2022). They also compa e
well wi h ano he pai am s udy using he same indica o , which es ima ed sligh ly
lowe mean p e alence o 5.6% o women and 4.9% o men (Passe -Wi ig e al.,
2020). The highe a e age p e alence in he cu en s udy could be due o he ageing
o he sample, as he o he s udy only used wa es 1 o 7. In ou sample, 30% o all
women and men ha e sough medical help o ha e a child. This also compa es well
wi h a s udy on non-mig an s and mig an s in Ge many (Milewski & Haug, 2022),
which is based on a di e en da a sou ce.
Impo an ly, ou es ima es p o ed a he obus o modi ica ions o he sample.
Fo he main analyses on pe cei ed in e ili y, obse a ions om esponden s who
epo ed a p egnancy o hemsel es o —whe e applicable— hei pa ne we e
excluded because hey we e no asked abou pe cei ed in e ili y. As a sensi i -
i y analysis ( esul s a ailable on eques ), we ea ed hese esponden s/couples as
Table 3 Help-seeking a es, by mig an s a us and pe cei ed in e ili y (%)
Calcula ions based on pai am wa es 7–12 (weigh ed da a). N o al = 1500 pe sons wi h n = 2345 obse a-
ions
Pe cei ed in e ili y Ra io o help seeke s pe cei ing in e il-
i y/help seeke s no pe cei ing in e ili y
Yes No Don’ know
Non-mig an 64.4 29.4 25.2 2.2
Mig an 43.0 23.0 16.7 1.9
To al % 57.8 27.4 20.9 2.1
n 137 552 58

In e ili y andSeeking Medical Help oHa e aChild Va y Ac oss… Page 21 o 38 25
e ile, based on he assump ion ha mos couples who achie e a p egnancy ha e
concei ed na u ally, and e- an he analyses. No subs an ial di e ences we e ound
when compa ing he e ec es ima es in his analysis wi h he indings in Tables7
and 8 in Appendix, indica ing ha he assump ion abou na u al concep ion was ea-
sonable. Howe e , his may change wi h inc easing use o medically assis ed ep o-
duc ion. I would he e o e be p e e able o ha e in o ma ion on how each p egnancy
was concei ed.
As is some imes he case in panel su eys, he ou ing o esponden s o he pe -
cei ed in e ili y ques ion was subjec o change. In wa es 2 and 3, p eload in o ma-
ion on in e ili y s a us was used in he il e . Responden s who conside ed hem-
sel es o hei pa ne s as de ini i ely in e ile we e no e-asked he same ques ion,
implici ly assuming hei s e ili y. F om wa e 4 onwa ds, he ques ion was posed
wi hou e e encing he p eload in o ma ion. To es whe he he condi ional il e -
ing in wa es 2 and 3 a ec ed he esul s, we conduc ed analyses excluding hese
wa es, bu ound no subs an ial di e ences ( esul s a ailable on eques ).
This s udy looked a medical help-seeking in he whole popula ion o women and
men o ep oduc i e age, which gi es a b oad pic u e o hose seeking help o ha e
child. These analyses showed ha mig an s we e less likely o ha e sough medical
help. Howe e , we would expec o ind a simila nega i e associa ion in a sample o
Non−mig an ( e .)
Mig an
(Bo h) e ile ( e .)
A leas 1 pe son in e ile
Don’ know i sel /couple (in) e ile
−.3 −.2 −.1 0 .1 .2 .3
M1 M2 M3 M4
Fig. 3 Help-seeking by mig an s a us and pe cei ed in e ili y (AME). Calcula ions based on pai am
wa es 7–12 (weigh ed da a). N o al = 1500 pe sons wi h n = 2345 obse a ions. AME a e age ma ginal
e ec s. Logis ic model; ull models a e a ailable in Table9 (Appendix). Model M2 con ols o sex, age,
pa en hood, and heal h. Model M3 addi ionally con ols o ma i al s a us/pa ne ship, educa ion, and
household income. Pe cei ed in e ili y is added in Model M4
N.Milewski e al.
25 Page 22 o 38
only people pe cei ing in e ili y, as mig an s a e o e - ep esen ed in his sample.
To es his, we e- an he analyses in a sample o 240 people pe cei ing in e ili y
(in wa es 7 o 10) and also ound a nega i e associa ion. Howe e , we a e ca e-
ul abou in e p e ing his inding because he cell sizes become e y small when
we di e en ia e be ween mig an s and non-mig an s. Mo e da a would be needed o
in es iga e his u he .
We also wan ed o include mo e li e s yle and heal h a iables—i.e. BMI, smok-
ing, alcohol—in addi ion o subjec i e heal h. He e, we aced some limi a ions. BMI
is upda ed e e y yea , bu only o he main sample and no o he Demodi sam-
ple, hus i con ains a lo o missing alues. Smoking was only included o he ull
sample in wa es 5, 7, 9, and only o he e eshmen sample in wa e 11. Alcohol
consump ion was only included in wa es 5, 7, 9, and 11. Including hem would ha e
esul ed in a la ge p opo ion o missing alues o hese a iables. Al e na i ely,
using only selec ed wa es would ha e been p oblema ic, gi en ha sel -pe cei ed
in e ili y among mig an s is a a he uncommon e en .
Finally, we conside ed andom e ec s panel models as an al e na i e es ima ion
me hod (see "Plan o Analysis" Sec ion) as an addi ional obus ness check. We es i-
ma ed andom e ec s mul inomial logi models o he in e ili y analysis and an-
dom e ec s logi models o he medical help-seeking analysis. We conclude ha
he indings a e obus o he es ima ion me hod and ha main conclusions o he
analyses emain alid ( esul s a ailable upon eques ).
Conclusion
This s udy examines di e ences in pe cei ed in e ili y and seeking medical help
o ge p egnan among mig an s compa ed o non-mig an s in Ge many, p o iding
insigh s in o a g oup o en o e looked in in e ili y esea ch, pa icula ly in Eu ope.
S udying mig an s and hei ep oduc i e heal h needs is pa icula ly impo an in
coun ies like Ge many and many o he Eu opean coun ies, whe e he mig an pop-
ula ion exceeds one qua e o he popula ion. Using ep esen a i e da a om he
gene al popula ion o e 12 wa es, we compa ed he pe cei ed in e ili y o women
and men and/o hei pa ne s and hei use o medical help o concei e wi h ha
o non-mig an s. Ou analysis included i s - and second-gene a ion mig an s om
a ious egions o o igin.
Con a y o ou expec a ions o a e ili y ad an age in he i s gene a ion and
among mig an s om coun ies a an ea lie s age o he second demog aphic ansi-
ion, he esul s did no consis en ly suppo hese assump ions. Ins ead, we obse ed
signi ican a ia ion among mig an g oups. In pa icula , a e ili y disad an age o
i s -gene a ion mig an s eme ged, challenging he no ion o a heal hy-mig an e ec
on e ili y. Fi s -gene a ion mig an s aced a highe isk o pe cei ed in e ili y
and we e mo e likely o exp ess unce ain y abou hei e ili y s a us. To pu hese
e ec s in o con ex , he p e alence o pe cei ed in e ili y in ou sample was app ox-
ima ely 8%, indica ing ha i is a ela i ely uncommon occu ence in he gene al
In e ili y andSeeking Medical Help oHa e aChild Va y Ac oss… Page 23 o 38 25
popula ion. Consequen ly, di e ences be ween social g oups we e modes , wi h an
inc ease o a ound 5 pe cen age poin s among i s -gene a ion mig an s compa ed
o non-mig an s and he second gene a ion (con olling o o he ac o s). Howe e ,
gi en he low baseline isk, his inc ease o 5 pe cen age poin s means ha mo e
han wice as many i s -gene a ion mig an s expe ience in e ili y compa ed o non-
mig an s—a ema kable scale e ec . Howe e , in e ili y is only one ace o ep o-
duc i e ajec o ies and ba ie s.
Ano he ele an ques ion is whe he mig an s and non-mig an s di e in hei
medical help-seeking beha io . Ou desc ip i e indings indica ed ha i s -gene -
a ion mig an s no only ace highe in e ili y a es, bu also show lowe u iliza ion
o in e ili y ca e. Addi ionally, we expec ed ha di e ences be ween mig an s and
non-mig an s would be less p onounced in he second gene a ion han in he i s .
Howe e , we ound no di e ences in he isk o sel -pe cei ed in e ili y o second-
gene a ion mig an s compa ed o non-mig an s, bu obse ed e en lowe ea men
a es compa ed o he i s gene a ion. Taken oge he , hese indings poin o a pa -
e n o “s a i ied ep oduc ion” wi h mig an g oups being double-disad an aged
compa ed o non-mig an s.
We obse ed di e ences in he isk o pe cei ed in e ili y acco ding o
mig an s’ egions o o igin. We expec ed lowe pe cei ed in e ili y among
mig an s om coun ies whe e e ili y pa e ns a e cha ac e ized by young bi h
ages and low childlessness compa ed o Ge many, which is cha ac e ized by la e
e ili y and high childlessness. Ins ead, we disco e ed highe a es o in e ili y
and unce ain y—and hus a e ili y disad an age—among g oups om Russia,
Kazakhs an, and he Middle Eas , including Tu key. S ikingly, ou desc ip i e
analysis sugges ed ha hese g oups ha e he lowes use o in e ili y ea men
in ou —admi edly—small sample. These indings imply ha p ocesses o e -
ili y dis up ion may be a ec ing he i s gene a ion and ce ain mig an o igin
g oups in pa icula . On he one hand, Ge many’s gene al, uni e sal heal h-ca e
sys em may, on a e age, acili a e he in eg a ion o mig an heal h ac oss gen-
e a ions. On he o he hand, e hnic ma ginaliza ion p ocesses may be e iden in
ce ain cases. Fu u e esea ch should look mo e closely a he unde lying causes o
hese di e ences. Finally, in he ealm o mig an e ili y esea ch, i is essen ial
no o au oma ically in e p e highe e ili y le els among mig an s compa ed o
non-mig an s as e idence agains e ili y dis up ion, o declining e ili y le els
among subsequen gene a ions as p oo o adap a ion p ocesses. Ins ead, u u e
s udies should sys ema ically compa e e ili y ideals and in en ions wi h ac ual
e ili y ou comes, and conside ep oduc i e ba ie s as an explana ion o de ia-
ions. Such s udies can complemen exis ing esea ch and shed ligh on he ex en
o which seemingly adap i e p ocesses a e due o delibe a e choices e sus in ol-
un a y ep oduc i e ba ie s. This would ul ima ely allow di ec assessmen o he
hypo hesis o e ili y dis up ion in mig an popula ions.
Fu he mo e, we examined a ious s ages o help-seeking. Ou analysis e ealed
signi ican di e ences among mig an s and non-mig an s in Ge many. Mig an s
a e signi ican ly less likely o ecei e ea men s which a e ypically p o ided by a
N.Milewski e al.
25 Page 24 o 38
gene al p ac i ione o gynecologis (only). In e es ingly, he e is i ually no di -
e ence in he use o ea men s ypically adminis e ed a e ili y clinics, such as
insemina ion o IVF. When ocusing solely on hose seeking any o m o medical
help, mig an s show an e en highe endency o unde go ea men in e ili y clin-
ics. This implies ha mig an s who ha e decided o seek medical help in concei -
ing a e mo e likely o seek mo e ad anced and in asi e ea men s. This inding is
consis en wi h a s udy showing ha i s -gene a ion mig an s in Ge many display
g ea e openness o medically assis ed ep oduc ion (MAR) and s onge in en-
ions o use MAR compa ed wi h non-mig an s (Haug & Milewski, 2018). Taken
oge he , hese indings unde line, on he one hand, ha help-seeke s ep esen a
dis inc g oup, demons a ing he impo ance o using gene al popula ion samples
o a comp ehensi e unde s anding o he p ocess o seeking medical help a a i-
ous s ages o ea men . On he o he hand, he easons o his inc eased openness
owa ds MAR among mig an s wa an a en ion. P e ious esea ch sugges s ha
s onge no ms ega ding ha ing biological child en and he signi icance o mo he -
hood play a c ucial ole in mig an g oups om coun ies wi h mo e amilis ic social
s uc u es. Consequen ly, in e ili y is a conce n o childless indi iduals o couples
as well as o amilies wishing o expand beyond one child. As his s udy shows, his
appea s o be impo an o conside in s udies o mig an s, bu should also be con-
side ed o non-mig an s.
Like all empi ical esea ch, his s udy has da a- ela ed limi a ions and o e s
sugges ions o u u e da a collec ion. We used a social science su ey in Ge -
many, which o he i s ime included ques ions on he sensi i e opic o in e ili y
and help-seeking. Al hough he pai am su ey co e s he gene al popula ion and
includes a ep esen a i e sample o immig an s, i does no o e - ep esen any pa -
icula mig an g oup. Due o he ela i ely in equen , hough no a e, occu ence
o in e ili y and help-seeking, he immig an case numbe s we e small, limi ing he
abili y o di e en ia e be ween mig an g oupings as desi ed. We conduc ed mul i-
a iable analyses o in e ili y based on mig an gene a ion and egion o o igin,
bu we e only able o make ai ly b oad g oupings by coun y o o igin. We did no
es ima e pe cei ed in e ili y sepa a ely o women and men because ou esea ch
sugges s ha in e ili y is a sha ed expe ience wi hin a couple, as is po en ial ea -
men . Howe e , many causes o in e ili y may be sex-speci ic and hus may indica e
speci ic p e en ion measu es and heal h-ca e needs o women and men. The e o e,
u u e analyses should also look a pa e ns o in e ili y by sex (T appolini & Giu-
dici, 2021). While he pai am da a p o ided a solid ounda ion o s udying popula-
ion he e ogenei y in pe cei ed in e ili y, i was less comp ehensi e o examining
medical help-seeking o ge p egnan . Mul i a iable models con olling o mig an
gene a ion o egion o o igin, le alone o bo h a iables simul aneously, we e no
easible. Consequen ly, he indings indica e a mig an disad an age, bu he a i-
a ion we ound be ween mig an g oupings based on me ely desc ip i e analyses
es s on less solid g ound. Ne e heless, bo h a iables—mig an gene a ion and
(pa en s’) egion o o igin—a e c ucial ma ke s o p obing wi hin-mig an di e si y
In e ili y andSeeking Medical Help oHa e aChild Va y Ac oss… Page 31 o 38 25
Table 8 (con inued)
Model 1 Model 2 Model 3
Fe ile In e ile Dk Fe ile In e ile Dk Fe ile In e ile Dk
Age in yea s ( e . < 35)
35 − 39 − 0.077** 0.070** 0.007 − 0.072** 0.065** 0.007
40 + − 0.138** 0.125** 0.013* − 0.130** 0.114** 0.016*
Pa en hood ( e . no) 0.091** − 0.041** − 0.050** 0.117** − 0.071** − 0.046**
Bad heal h ( e . good heal h) − 0.032** 0.028** 0.004 − 0.029** 0.028** 0.001
Ma i al s a us/pa ne ship ( e .
ma ied)
No pa ne 0.052** − 0.068** 0.015**
Unma ied 0.028** − 0.040** 0.012**
Educa ion ( e . p ima y/lowe seconda y)
Highe seconda y − 0.121** 0.083** 0.039**
Te ia y − 0.043** 0.032** 0.011**
Missing alue − 0.200** 0.205** − 0.005
Calcula ions based on pai am wa es 1–12 (weigh ed da a). N o al = 12,777 pe sons wi h n = 58,802 obse a ions
AME a e age ma ginal e ec , Dk Don’ know, NWCSSE No h, Wes , Cen al, Sou h, Sou h-Eas Eu ope
* p < 0.05, **p < 0.01
Model 3 includes wa e as a con ol (no shown, a ailable on eques )

N.Milewski e al.
25 Page 32 o 38
Table 9 Resul s o he mul i a iable logis ic analysis on he p obabili y o medical help-seeking o ha e a child, all esponden s (AME)
Calcula ions based on pai am wa es 7–12 (weigh ed da a). N o al = 1500 pe sons wi h n = 2345 obse a ions
AME a e age ma ginal e ec
* p < 0.05, **p < 0.01
Model 4 includes wa e as a con ol (no shown, a ailable on eques )
Model 1 Model 2 Model 3 Model 4
Mig an ( e . non-mig an ) − 0.084* − 0.074* − 0.083** − 0.083**
Women ( e . men) 0.093** 0.099** 0.092**
Age in yea s ( e . < 35)
35 − 39 0.085** 0.062* 0.049
40 + 0.178** 0.157** 0.114**
Pa en hood ( e . no) − 0.208** − 0.225** − 0.212**
Bad heal h ( e . good heal h) 0.081* 0.097** 0.083*
Ma i al s a us/pa ne ship ( e . ma ied)
No pa ne − 0.168** − 0.164**
Unma ied − 0.129** − 0.122**
Lowe educa ion ( e . highe educa-
ion)
− 0.043 − 0.051
Household income in € ( e . < 1500)
1500–2500 0.091 0.093
2500–3500 0.054 0.047
3500 + 0.114* 0.105*
Missing alue 0.028 0.034
Pe cei ed in e ili y ( e . (bo h)
e ile)
A leas 1 pe son in e ile 0.201**
Don’ know i sel /couple (in)
e ile
− 0.073
In e ili y andSeeking Medical Help oHa e aChild Va y Ac oss… Page 33 o 38 25
Funding Open Access unding enabled and o ganized by P ojek DEAL. No applicable.
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E hical App o al No applicable.
Pa ien Consen S a emen No applicable.
Pe mission o Rep oduce Ma e ial om O he Sou ces No applicable.
Da a A ailabili y The da a ha suppo he indings o his s udy a e openly a ailable in GESIS a h ps://
doi. o g/h ps:// doi. o g/ 10. 4232/ pai am. 5678. 14.1.0.
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