Why Do We Treat Infertility Like It’s Just Rich Women’s Problem?

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Photo: Rawlins PhD/Getty Images

When Ann V. Bell, an assistant professor of sociology at the University of Delaware, started combing through infertility research back in 2008, it didn’t take long for her to notice a pretty gaping hole: The existing infertility literature focused almost exclusively on the experience of affluent white women. “We only got the perspective of those who went to infertility medical clinics for their treatment — since that’s where all these studies were recruiting participants — and the primary demographic at these clinics are white individuals of high socioeconomic status (SES),” she told the Cut.  

Yet despite their overwhelming representation in the media and pop culture, infertility isn’t just a thing that happens to rich white women: According to the Center for Disease Control and Prevention, 11 percent of women ages 15 through 44 have difficulty getting pregnant or carrying a pregnancy to term. Bell argues that part of the reason the infertility of poorer women is so rarely discussed comes back to deeply ingrained societal stereotypes about reproduction and who should mother. “There’s still this idea that white, wealthy women aren’t having enough kids, and that poor women — and poor women of color especially — are hyperfertile, and having too many kids,” she explained. “It makes it hard to imagine that poor women are having any infertility problems.” Yet the invisibility of poorer women’s pregnancy struggles also comes back to the fact that, currently, there aren’t a lot of options for them. According to Bell, one cycle of in vitro fertilization treatment typically costs around $12,400 — and adoption often poses a comparable financial drain.

With this in mind, Bell set out to study the largely ignored infertility experiences of women of low SES. Between 2008 and 2010, she conducted in-depth interviews with white and black women of varied socioeconomic status, and she published her findings in a new book, Misconception: Social Class and Infertility in America, out this month from Rutgers Press. The Cut spoke with Bell about the factors that make infertility particularly bleak for poorer women.

You point out that infertility is almost exclusively discussed and represented in the media as an issue affecting affluent white women. What factors contribute to that stereotype?
The stereotype of poor women as hyperfertile is really ingrained. Even while I was recruiting participants of low socioeconomic-status for the study, I ran into some hesitation and resistance from agencies that serve the low SES population. For instance, I asked if I could post a flyer in a particular organization that catered to poor women, and one of the workers said, “Well, you can, but you’re not going to get any participants because they actually have the opposite problem” — meaning that they’re having too many children.

And then there’s also the fact that what we see in the media are the medical experiences of infertility — so those women who get medical treatment, who tend to be high-profile: celebrities who get surrogates, or have twins, or that kind of thing.

How do approaches to resolving infertility vary among women of different classes?
A lot. Women of high SES typically automatically go to their physician or medical clinic to receive treatment for their fertility troubles. Whereas women of low SES — first of all, they usually don’t recognize their fertility problems for much longer, since, for the most part, they’re not using mechanisms like temperature taking and ovulation kits. And then, once they do, many times they don’t have access to medical options for financial reasons — their insurance won’t cover them seeking out medical care for their infertility, or, in many cases, they avoid medical treatment for discriminatory reasons. One woman told me, “Why in the world would I go to a doctor for my infertility when physicians always discourage me from getting pregnant?” So instead they’ll try folk methods, like rubbing pregnant women’s bellies, or eating certain types of food — like certain teas, or an egg McMuffin, one woman told me.

That being said, however, many women of low SES do seek medical advice — not necessarily for infertility treatment, since they know they won’t be able to afford it, and many of them don’t even trust it, given their discriminatory experiences in the past — but they do still want to know why they aren’t getting pregnant. Unfortunately, many of them aren’t able to get an answer because they can’t get a referral to a specialized reproductive endocrinologist, or they can’t afford the tests that have to be run to give them a diagnosis.

Your book also talks about the ways that poor women are often excluded from infertility treatment besides just cost.  
Yeah, it goes beyond just financial inaccessibility. Something as simple as appointment scheduling: Fertility clinics are usually [open from] 9 to 5, and women of low SES are, first of all, much more likely to be working, and also more likely to be working in positions that don’t allow them much flexibility with their working hours. Infertility treatment is very demanding on your time — even among women of high SES, I spoke with two women with very high-profile jobs who had quit their jobs in order to meet the demands that the infertility treatment required. For women of low SES, the co-pays are also difficult, as is their insurance status — some women who receive Medicaid insurance as opposed to employer-based insurance or private insurance got discriminatory remarks from physicians, or were simply told, "you can’t" — or they didn’t even ask because they’ve already been told so many times, “you can’t do this, you can’t do that.” Even just the discriminatory remarks make women much more hesitant to access medical care. I had a woman tell me that she asked for help getting pregnant, but the physician she was seeing just kept pushing birth control.

Do you believe that doctors discourage poorer women from having children?
I mean, it certainly was very blatant and apparent in the stories the women of low SES told me. It was prevalent, and very much a part of the story line that I heard among the women of low SES.  

How does the dominant representation of infertility as a rich white woman’s problem affect the women who don’t fit that profile?
Very much. They’ve internalized these stereotypes, and many times refer to things they see or TV, or mention things like, well, I don’t know another black woman who’s infertile, or, I don’t know another woman in my community who’s infertile. They feel very isolated. Whereas women of high SES recognize that they do fit the stereotype that we have, and they also tend to know other women who have experienced infertility, either from support groups, or fertility clinics, or because women of high SES tend to delay childbearing — so they have acquaintances and friends who have gone through fertility difficulties and can relate.

You also asked the women you interviewed about why they wanted to be mothers. Did women of different classes have different answers?
I find that really fascinating. It’s not a question that’s usually asked — we usually just assume that women want to mother because womanhood and femininity are so embedded and associated with the idea of motherhood that they’re sort of one and the same. But implicit in the idea of infertility is that you want to mother because you wouldn’t recognize your infertility otherwise. And especially with all the stereotypes around class, and who’s a “good” mother and who’s a “bad” mother, I wondered, Why do poor women want to mother when there are all these stereotypes and social norms telling them that they shouldn’t?

I asked all of the women in the study why they wanted to mother, and I’d say that the women of low SES are more outcome-focused. They talk about what the baby will give them as individuals. For instance, love is always a big answer among women of low SES — they want to be able to give love, but they also want to receive love. I think many times they’ve had difficult and challenged backgrounds where they didn’t necessarily receive love in the way they imagined or wanted to. Or they would say, “I want to have a baby so I can calm down and become an adult,” or grow up. What the baby would give to them as individuals was what the women of low SES would cite as their motivation for wanting to mother.

In contrast, the women of high SES’s motivation to mother was more based in the ideological narratives and norms around motherhood. So, they want to mother because that’s the next stage in their lives — or because I’m married, I’m employed, I’m in my mid-30s, and to be a legitimate family — or a legitimate woman —I need to have a child. I should also say that women from both classes have what I call the “good mother syndrome”: I didn’t have a single participant who didn’t think that she would be a good mother. What that means differs, but everybody thought they would be.