Abstract
Misconception turns conventional—and sociological—wisdom about infertility on its head. Ann V. Bell demonstrates that infertility is not the exclusive affliction of affluent women, as we might expect from representations in popular culture and social science texts, but is at least as (if not more) common among women who are poor or working class. The book compares women’s experiences of infertility by social class, finding important differences in how wealthy/middle-class and poor/working-class women conceptualize mothering, identify problems, use technology, gain social support, and cope with the loss that can result from infertility. Perhaps most importantly, Bell links these experiences with class differences in women’s pregnancy intentions, bringing together two literatures—infertility and fertility intentions—that sociologists, demographers, and public health scholars have treated as unrelated for too long. This link is a revelation, the kind of finding that makes one wonder how it went unnoticed for so long. This insight alone makes the book worth reading for scholars of family, medicine, gender, and reproduction, as well as for those who study family planning and fertility.
Bell convincingly demonstrates that the fertility of wealthy and poor women is valued differently and that these cultural understandings influence social policies and medical institutions. For this reason, she insists that infertility “is not merely a medical condition, but a quintessentially social phenomenon” (p. 82). As such, she spends relatively little time discussing the intricacies of infertility treatment and instead devotes most of the book to women’s interactions with partners, family, friends, bosses, and medical professionals. This is significant because Bell finds that many poor and working class women do not ever reach infertility clinics. Sometimes this is due to economic factors and differences in insurance coverage, but just as often it results from their lack of knowledge about treatments, their reluctance to seek them, and—perhaps most disturbingly—the classism and racism of health care providers who seek to limit their fertility rather than enhance it.
Bell employs a comparative research design, conducting in-depth interviews with fifty-eight women aged 18 to 44 who experienced involuntary childlessness for at least a year (p. 8). Compared to other work on infertility, what is unique about her sample is that over two-thirds of these participants are what Bell calls “low SES [socioeconomic status] women” who identify as white or black. The remainder of her sample is composed of white “high SES women.” (Bell also interviewed three black high SES women and two Latinas of undisclosed SES, but decided not to include them because of the small numbers in these groups.) Acknowledging that social class is a complicated construct, Bell first used women’s household income to group them, then drew on their occupations and their and their families’ educational attainment to refine these placements (p.143). Bell determines that each group is homogenous in these patterns and quite distinct from the other, which she argues is consistent with other studies of social class and mothering.
As Bell points out in a trenchant critique, “infertility” is primarily considered a medical condition in the United States. By focusing on “involuntary childlessness” and avoiding the word “infertile” in her recruitment efforts, Bell made a concerted effort to include women who may not have seen themselves as such or who did not subscribe to medicalized views. As a result of her emphasis on childlessness, it appears that all of the women Bell interviewed suffered from infertility from the beginning of their reproductive lives. There is no reference to what is often referred to as “secondary infertility,” or the inability to conceive after giving birth to a biological child, or to any previous children that women may have had. Focusing on women who have never had children is certainly a reasonable strategy, but Bell does not acknowledge that her eligibility criteria exclude a high percentage of women who experience infertility.
Bell illustrates that infertility “is based in ideological notions and influenced by the context in which it occurs” (p. 82). Unfortunately, the most serious limitation of this study is the lack of context provided for many of the findings. Bell describes her respondents primarily in terms of her groupings of high or low SES and their race, only rarely giving more details about the woman (such as her occupation, education, or family composition, including any children that women may have eventually borne or adopted). Similarly, Bell describes her use of quotations as “illustrative” (p. 145), but often neglects to report how many women share a characteristic or experience. For example, Angie, “a black woman of low SES,” says she does not know of any infertility support groups (p. 72); Bell does not specify how many other low-SES respondents were similarly unaware of such resources. Bell notes that some states mandate Medicaid coverage for infertility treatments (p. 5) but does not indicate whether or not her respondents lived in any of these places at the time of their involuntary childlessness. By not including this type of contextual information, Bell limits the reader’s ability to evaluate her claims, particularly her central thesis that the differences in women’s experiences result primarily from their class locations and not other factors.
Similarly, Bell’s analyses are focused primarily on the underrepresented groups: black and white women of low SES. This strategy makes sense, given that most of the scholarship on infertility has focused on wealthy women. More exposition of high SES women’s experiences would have enhanced the comparison: for example, there are only five paragraphs (pp. 19–22) on high-SES women’s motivations for mothering and more than twice as many on low-SES women’s motivations (pp. 16–19). Additional discussion could clarify the distinctions between the two groups.
Finally, although Bell does devote considerable attention to the constraints low-SES women face, certain passages could be read as perpetuating damaging stereotypes about low-SES women. To give one example, she generalizes from a single quote (which, again, may or may not reflect a larger pattern) to conclude that “the women of low SES actively choose not to use contraception with the intent of conceiving a child, but they do not acknowledge it as a decision or plan because they view it as a natural part of intending to become pregnant” (p. 45). Here Bell reduces an extremely complicated set of conditions to the proposition that low SES-women who do not use contraception intend to conceive. This conclusion minimizes the barriers low-income and poor women face in securing adequate contraception and risks blaming them for their disproportionate share of induced abortions (Jones, Finer, and Singh 2010).
The clarity of Bell’s thesis and the relative brevity of the book will make Misconception a particularly useful text in undergraduate courses on social class, reproduction, and family. Despite its limitations, Misconception will inspire new connections among the overly segregated subfields of reproductive health, and it advances our understanding of infertility.