Misconception: Social Class and Infertility in America

Ann V. Bell

New Jersey: Rutgers University Press, 2014

Reviewed by Jill Allison

Misconception provides a powerful collection of narratives of infertility across the socio-economic spectrum in America.  Ann Bell argues that it is SES that most deeply marks the variations in women’s experiences of infertility and their access to any kind of medical or social support.  But perhaps more importantly, Bell provides a glimpse of the many social and structural elements in women’s lives that shape the meaning of reproduction and motherhood.  Like many socially grounded studies on infertility, it is this lens on motherhood that infertility affords us that makes Bell’s work an important contribution to medical social science.  Bell argues that women in low SES groups make reproductive decisions differently, approach motherhood differently and view an inability to conceive from a more fatalistic perspective.  Locating the ideals of motherhood in the middle and upper class notion of planning and preparing, being ready and able to provide materially for a child before embarking on motherhood, Bell points out how women in low SES groups are excluded from the normative picture of the ideal mother.  For these women, motherhood can be a “redemptive” endeavor (p.60) that fills a potential absence of loving relationships with parents or with partners who may or may not be committed to a relationship.

The strength of the book is in the narratives of the women, particularly with respect to their relationships to and experiences with the medical system.  Structural violence is evident in many stories in which the impact of a demanding appointment schedule or the prescribing of expensive medications for the working poor who happen to have minimal health insurance is never considered. The role of physicians and clinics as gatekeepers not only of treatment and services, but of motherhood itself, based on the socially sanctioned view of economic readiness is clear in Bell’s work.  Bell also affirms the work of Naomi Pfeffer (1993) and Sarah Franklin (1997) who have described the medicalization of infertility and its construction as a disease by virtue of the treatment options now available.   However, Bell does a good job of pointing out how this diagnosis is relevant only to those who can pay for treatment.  Bell’s book provides ample insight into the distinction between infertility experiences of high and low SES: Infertility is not an illness among the poor but rather a condition of life that is lived with and not overcome.  The other key argument that Bell draws from her narrative data is that decision-making around pregnancy is highly nuanced and subject to the social definition of ideal motherhood. Her discussion on the fine distinctions between letting pregnancy happen and actively planning for pregnancy is situated against the backdrop of the “unintended pregnancy” – a concept associated with irresponsible motherhood among women of low SES.  Bell’s argument powerfully dismisses as a false construction, the notion of intention as defined solely by actively planning for pregnancy.  The social context in which it is only acceptable to plan for a child if one is financially stable shapes how women in poverty approach their desire to be mothers.

Bell locates infertility experiences within the social context of America, but the book does not draw many links between the capitalist profit seeking nature of American healthcare and the fact that infertility experiences would not be unique in highlighting such sharp divisions between high and low SES.  While the distinctions between women of low and high SES are important, there seems to be no middle ground in this account, and people in so called “middle class” SES are rarely mentioned even though their experiences might further illuminate the pressures women feel to seek treatment or meet a social ideal.  There are some generalized conclusions around “black culture” and rates of marriage that would benefit from some context around national statistics.  It is a bit unclear in the book just how significant racialized experiences might be within various SES since there is no data on the experiences of women of color in high SES.  Bell argues that it is low SES that matters most, but this risks obscuring specificities and differences in relations of power as second and third wave feminists have rightly noted.

This book makes an important contribution to the literature on access to reproductive technologies, the importance of SES and a reproductive choice, the social context of a motherhood identity, and the role motherhood plays in the individual life plans of women.  As a feminist text, it is light on theoretical analysis but this makes it broadly accessible to social scientists and scholars from a range of disciplines who are looking to understand the impact of social stratification on reproductive decision-making.


Jill Allison holds a PhD in medical anthropology.  Her work addresses the impact of reproductive technologies on social values in Ireland, access to safe motherhood and health and social justice in Haiti and Nepal. She is Clinical Assistant Professor and Global Health Coordinator in the Faculty of Medicine at Memorial University of Newfoundland in Canada.

Comments are closed.