IMPORTANCE OF MOTHERHOOD AND/OR SOCIAL STIGMA OF INFERTILITY: ING INFERTILITY-RELATED OUTCOMES? By  Bette Eulalie Avila           A DISSERTATION  Submitted to  Michigan State University in partial fulfillment of the requirements for the degree of  SociologyDoctor of Philosophy  2016     ABSTRACT IMPORTANCE OF MOTHERHOOD AND/OR SOCIAL STIGMA OF INFERTILITY: -RELATED OUTCOMES? By  Bette Eulalie Avila Data from the National Survey of Family Growth suggested that 6.0%, or 1.5 million married women, faced infertility in the United States between 2006 and 2010, which is clinically defined as the inability to achieve pregnancy after one year of regular unprotected intercourse for those under age 35 and six months of regular unprotected intercourse for those age 35 and over (Chandra et al., 2013). Infertility not only has physical consequences, but emotional and psychological consequences, including feelings of failure, injustice, and depression and these feelings are long-lasting. These feelings may arise from the importance that individual women tend to place on becoming a parent to a biological child, or the psychological drive to bear a child (Brothers & Maddux, 2003; McQuillan et al., 2008). However, research has also tended to argue that infertility has a profound impact on women because motherhood is intimately linked to gender identity, especially in pronatalist countries whose societies view  illing predominant norms of femininity (Arendell, 2000; Loftus, 2009; McQuillan et al., 2015; Park, 2002; Ulrich & Weatherall, 2000). When a woman is unable to reproduce, she may face stigma associated with her infertile status, even if she chooses not to publicly disclose her struggles. This stigma may take the form of unwanted questioning from friends, family members, or even strangers regarding when a woman plans on having children if she is within the childbearing years. Using (1963) theory of stigma as my primary framework, I argued that stigma relates to      invisible as well as visible illnesses, and that this also applies in the context of infertility, a seemingly invisible illness.  Overall, despite the importance of stigma in the context of infertility, women may place a great deal of importance on biological motherhood. In this dissertation, I conceptualized the importance of motherhood  psychological motivation towards bearing biological childbearing, and juxtaposed this to structural level stigma, or the social pressure for all women to bear biological children. Prior research has found that some women link having biological children to happiness and life satisfaction (Brothers & Maddux, 2003). When a woman cannot achieve biological motherhood when it is a strongly desired personal goal, she may therefore still feel the same sense of loss as someone facing the pressures of stigma associated with her inability to bear biological children.  Given the powerful influence of both stigma and the individual importance placed on motherhood, I sought to explore which of these may have a greater influence on infertility-related outcomes for women. Using the National Survey of Fertility Barriers, a large dataset that includes detailed fertility information, including fertility desires and psychological variables, I analyzed these two factors, personal importance placed on motherhood and the stigma of infertility, and their potential relationship to two infertility-related outcomes using regression. These infertility-related outcomes included: 1) fertility-specific distress, 2) confidence in biomedicine to remedy infertility. In addition, I incorporated the potential moderating effect of social support on fertility-specific distress in the second chapter of the dissertation.iv  This dissertation is dedicated to my husband, Diego, and son, Ephraim. They are the light of my life and gave me the inspiration to finish my PhD.  Los quiero tanto, mis amores.v  TABLE OF CONTENTS  ..vii  .1 Infertility and Distress: A Product of Individual Psychology or Socio-Structural Pressures Toward Biological Motherhood?.........................................................................................1 REFERENCES  CH12 Importance Placed on Motherhood or Social Stigma -Specific Distress? ...............................................................................12 Introduction...12 Literature Review..13 Fertility-specific distress..13 Pronatalist social norms and the stigma of infertility...14 Importance of motherhood.......17 Intention to have a baby.18 Race/ethnicity and income....19 Employment status Age Methods.22   Data..22   Measures.23   Analytic strategy25  Results25   Descriptive statistics.25   Regression results Discussion and Conclusion.31  REFERENCES.38  .42 Social Stigma of Infertility and Importance Placed on Motherhood: Does Social Support Moderate the Relationship With Fertility-Specific Distress?...........................................42 Introduction...42 Literature Review...44  Fertility-specific distress.44  Social support45  Pronatalism and the stigma of infertility6  Importance of motherhood49   Intention to have a baby50  Sociodemographic characteristics...51  Race/ethnicity and income51  Employment status53 vi   Age53 Methods.................54  Data..54  Measures55  Analytic strategy  Results...58   Descriptive statistics...................................................58   Regression model results.63  Discussion and Conclusion.....65  REFERENCES.73 ..78 Social Stigma of Infertility and Importance Placed on Motherhood: Does Either Influence Faith in Medical Interventions in the Context of Infertility?............................................78 Introduction.......78 Literature Review.80  Pronatalism and the stigma of infertility..............................................................80  Importance ..81  Use and access to infertility treatment.83  Race/ethnicity, income, and employment status.84  Age85  Intention to have a baby.86 Methods  Data.87  Measures88  Analytic strategy90  Results   Descriptive statistics.90   Regression results.94 Discussion and Conclusion..96 REFERENCES..103   114    vii  LIST OF TABLES Table 1. Descriptive Statistics for the Sample for Analysis of Importance of Motherhood and Stigma of Infertility on Fertility-specific Distress....26 Table 2. Descriptive Statistics for White Respondents .27 Table 3. Descriptive Statistics for Black Respond  Table 5. Regression Models for the Importance of Motherhood and Stigma of Infertility on Fertility-..31 Table 6. Descriptive Statistics for the Sample for Social Support, the Importance of Motherhood, and the Stigma of Infertility on Fertility-specific Distress..59 Table 7. Descriptive Statistics for White Respondents .60 Table .61 .62 Table 10. Regression Models for Social Support, the Stigma of Infertility, and the Importance of motherhood on Fertility-specific Distress .....65 Table 11. Descriptive Statistics for the Sample for the Importance of Motherhood and the Stigma .91 Table 12. Descriptive Statistics for White Respondents ..92 ..93 .94 Table 15: Regression Models for Stigma of Infertility and the Importance of motherhood on Confidence in Biomedicine96   1  INTRODUCTION Infertility and Distress: A Product of Individual Psychology or Socio-Structural Pressures Toward Biological Motherhood? A major theme associated with infertility in the social science scholarship is infertilityrelation to gender identity and how this relationship is connected to both social and psychological responses (Greil, 1997; Greil et al., 2010). Specifically, some researchers have argued that wominterwoven with the ability to bear biological children (Arendell, 2000; Loftus, 2009). The connection between gender identity and the ability to bear biological children is associated with pronatalist social norms in many countries, including the U.S.1 (Arendell, 2000; Loftus, 2009; McQuillan et al., 2015).  Scholars have called the where motherhood is accorded high status (Arendell, 2000; Loftus, 2009; McQuillan et al., 2015; Park, 2002; Ulrich & Weatherall, 2000). Pronatal ability to procreate (Ulrich & Weatherall, 2000) and some have argued that this is especially true for women who consider the expectation to be a mother as one of the most important life goals and sources of life satisfaction (McQuillan et al., 2008). Scholars have also argued that becoming a mother is deeply intertwined with what it means to be a woman, and hence, notions of femininity within U.S. society (Arendell, 2000; Loftus, 2009). Based on this line of thinking, motherhood                                                            1 Examples of anti-instituted in 1979) and other Asian countries such as India and Singapore. The aim of these policies was to decrease the total fertility rate and the crude birth rate, to slow the rapid population growth in these countries (see Connelly, 2006; Feng et al., 2012; Yap, 2003).  2  reinforces conceptions of femininity include nurturance and care of others, particularly children. Thus, gender scholars have discussed the linkage between motherhood and gender identity as a social construction (Elvin-Nowak and Thomsson, 2001), but a social construction that retains a high amount of influence on individual women. Some scholars have even argued that no other gendered discourse has patterned  Although there are other avenues of becoming a mother (e.g. adoption), research has suggested that society considers these avenues as Parry, 2005; Wegar, 2000).   When a woman is unable to fulfill pronatalist social norms, she may experience great distress because of the related social stigma. The distress arising from infertility may lead to a secrecy around the condition, withdrawal from social interaction, or a motivation to go to great lengths to remedy the situation through medical interventions, despite the potential effects on the body and mental wellbeing (Cousineau & Domar, 2007; McQuillan et al., 2007). This is not to imply that women are agentless pawns of a social system that advocates biological reproduction, particularly because not all women embrace pronatalist norms. Indeed, some women do not desire children, but may nevertheless experience the social backlash of failing to fulfill the norms of biological reproduction. Because childbearing is a personal choice, although one highly influenced by social expectations, pronatalist societies largely view women without children as uncaring or selfish (Mcquillan et al., 2012).  Furthermore, the expectation that women are to become deeply nurturing and sacrificial mothers to their biological children is crucial to understanding the social pressure for women to bear biological children. Prior research on motherhood has emphasized that the status of 3  motherhood holds historically deep meanings about gender and femininity, such as the characteristics of nurturance, protection, and socialization of children, and that no other gendered (Miller, 2007, p. 337). Essentially, U.S. society, among other pronatalist societies, places an emphasis the prenatal period and continues through to the adulthood of a child. Good mothering begins with a focus on  a doing what is best for the fetus regardless of the discomfort or health of the pregnant woman) and continues to her lifelong personal sacrifice to meet the needs of her children (Miller, 2007). Clearly, a precursor to meeting the social demands to become a selfless pregnant woman and sacrificial mother is the ability to bear a biological child 2. Taking this information on pronatalism, gender and identity, I utilized theory of stigma to understand the consequences of infertility-related stigma in the face of infertility. As Goffman (1963) explainedexpose something unusual and bad about the moral status of the  concept of stigma involves the societal categorization of individuals based on attributes that are considered in line with the normative social order. Social settings provide the context for which characteristics are deemed normative, and allow individuals within that social setting to categorize others without giving special thought or attention to the process. First appearances allow us to anticipate and classify others into socially defined categories that are engrained in our minds through repetitive interactions with others. These categories could include individual                                                            2 s they may experience. This is a topic ripe for future exploration, but not the focus of this dissertation because of the stronger gendered expectations for women to bear biological children. Please see Gannon and colleagues (2004) or Throsby & Gill (2004) for examples of the existing research on  4  personality traits such as honesty, physical traits such as bodily ability, and structural traits such as occupation. Ultimately, we categorize other individuals in society without conscious reflection, until someone falls outside the bounds of what is considered socially normative. For example, if we encounter someone who, upon first inspection, is determined to possess a less than desirable trait that falls outside normative social boundaries, we will begin to reduce that person in our minds to less than a usual and whole person, to a discounted and tainted one. This process is defined as stigma, and refers to an attribute that is deeply discrediting.  It is also important to note that the relationship between attributes and stereotypes matters in the context of stigma: an attribute that stigmatizes one individual may be perfectly acceptable for another individual to possess and merely demonstrates their social usualness. For example, someone may attempt to cover up their educational level within a blue collar occupation in order to fit in with coworkers, while someone else may lie on a job application and inflate her educational attainment to appear as a better qualified candidate for a position. However, this is not to imply iting in all situations. Obesity is one example, since society generally considers visibly overweight status a sign of defectiveness because it deviates from socially sanctioned norms about body types that represent optimum health. However, Goffman also argued that stigma is more commonly used to describe the disgrace itself, rather than the bodily evidence. This distinction between the disgrace itself and the bodily evidence is pertinent when discussing infertility, an invisible marker of stigma, but a marker nonetheless. Although infertility is an invisible stigma, insofar as other members of infertility is still visible in terms of a lack of children and visibly categorized because medical professionals diagnose 5  infertility as a physical illness. In addition, pronatalist societies, such as the U.S., set forth normative expectations for women to include biological motherhood. When a woman does not fulfill this expectation during her childbearing years, she is deemed deviant and thereby stigmatized.  Therefore, in this dissertation I focused on women only and took into account both the social stigma of infertility and the importance that individuals place on motherhood, since both exist within society and infs to infertility. I analyzed how the social stigma of infertility compared to the importance placed on motherhood affect three potential facets of the infertility experience: fertility-specific distress, confidence in biomedicine to remedy infertility, and the potential moderating effect of social support on fertility-specific distress. The goal of this comparison was to understand which of these, the importance placed on motherhood or the stigma of infertility, had a greater relation to fertility-specific distress and confidence in biomedicine, as well as exploring the potential moderating effect of social support on fertility-specific distress. To meet the aims of this dissertation, I conducted a secondary analysis of the National Survey of Fertility Barriers (NSFB) survey data. The National Institute of Child Health and Development (NICHD) funded the original study,  Researchers conducted NSFB survey collection between 2004 and 2007, and specifically asked respondents about biomedical fertility barriers including infertility, subfecundity, repeat miscarriage, health conditions that preclude biological reproduction, and sterilization regrets. In total, NSFB researchers interviewed 4,712 women and 936 partners in a collaborative effort between the University of Nebraska-Lincoln, Penn State, Alfred University, The University of Connecticut, and The University of Nebraska Medical Center. The Survey 6  Research Center at The Pennsylvania State University and the Bureau of Sociological Research at the University of Nebraska-Lincoln collected the data via telephone survey using a random digital dialing sampling strategy with phone numbers purchased from Survey Sampling, Inc. Researchers collected an oversampling of African American women and Latinas from Census tracts with over 40% minority concentration. Waves 1 and 2 of the data are available through SODAPOP, or the data archive of the Population Research Institute at The Pennsylvania State University. Access is restricted to the data, and users must provide their names, institutional affiliation, and contact information to obtain it.  In the first empirical chapter, I analyzed the influence of social stigma of infertility on fertility-specific distress and compared this to the personal importance placed on motherhood and its influence on fertility-specific distress. Prior research has suggested that infertility is associated with fertility-specific distress (Greil, 1997; Greil et al., 2010; Slade et al., 2007) and that the distress can be as serious as that associated with cancer, heart disease, and HIV positive status (Cousineau & Domar, 2007). Pronatalist social norms present in the U.S. and social messages arising from these norms contribute to fertility-specific distress (Goffman, 1963; Miall, 1985). Less research has differentiated between the societal and personal factors that may contribute to distress (McQuillan et al., 2012), although personal desires for children also influence the drive to bear biological children (McQuillan et al., 2008) and this may affect distress. In this chapter, I attempted to remedy this gap in the literature by differentiating between these two levels, the psychological and the structural, and their relation to fertility-specific distress. In the second empirical chapter, I delved into an analysis of the potential influence of social support as a moderating factor between the social stigma of infertility and fertility-specific 7  distress and the importance of motherhood and fertility-specific distress. Despite the power of pronatalist norms in influencing fertility-specific distress and the personal importance that many individuals place on becoming a parent, research has found that social support is important to alleviating fertility-specific distress (Gibson & Myers, 2002; Lechner et al., 2006; Martins et al., 2011). Researchers have called social support a critical component of how women adjust to the stressors of infertility, particularly because they may disclose their status to others (Martins et al., 2011). Thus, in this chapter I interrogated which of these, importance of motherhood or the stigma of infertility, had a greater influence on distress while taking into account the moderating role of social support. In the last empirical chapter, I analyzed the influence of the stigma of infertility and the importance of motherhood on confidence in biomedicine to remedy infertility. Medical intervention is one recourse to the infertility dilemma, regardless of whether someone is driven to reproduce because of social pressures or personal desires to bear biological children. Prior research has shown that biomedicine has a powerful influence in the west, in particular, because of prevailing social beliefs in the ability of biomedicine to remedy any physical ailments and illnesses (Becker, 2000). Women may place great faith in medical interventions to remedy infertility because of the gender norms associated with biological reproduction and a desperation to achieve pregnancy at any cost. However, women may also place great confidence in biomedicine for reasons aside from social pressures to bear children, such as a great personal desire to have a child. In order to test these differing views, I aimed to explore the potential association of the importance of motherhood and confidence in biomedicine and the stigma of infertility and confidence in biomedicine. Overall, I hoped to elucidate which of thesethe stigma of infertility or the importance of motherhoodhad a greater influence on fertility related 8  outcomes. I concluded the dissertation with a discussion of the findings in the context of d the substantive and methodological contributions of the current analysis. I then moved on to a summary of the limitations of this research. Finally, I provided directions for future research in this area, emphasizing an increased focus on the integration of the social-structural and psychological level factors influencing fertility-related outcomes.9  REFERENCES  10  REFERENCES  arship.  Journal of Marriage and Family, 62, 1192-1207. Becker, G. (2000). The Elusive Embryo. University of California Press: Berkeley, CA. Connelly, M. (2006). Population control in India: Prologue to the emergency period. Population and Development Review, 32, 629-667. Cousineau, T., & Domar, A. (2007). Psychological impact of infertility. Best Practice and Research: Clinical Obstetrics and Gynaecology, 21, 293-308. Elvin-Nowak, Y., & Thomsson, H. (2001). Motherhood as idea and practice: A discursive understanding of employed mothers in Sweden. Gender & Society, 15, 407-428. Feng, W., Cai, Y., & Gu, B. (2012). Population, policy, and politics: How will history judge -child policy? Population and Development Review, 38, 115-129.  Fisher, A. (200Annual Review of Sociology, 29, 335-361. Gannon, K., Glover, L., & Abel, P. (2004). Masculinity, infertility, stigma and media reports. Social Science & Medicine, 59, 1169-1175. Gibson, D. & Myers, J. (2002). The effect of social coping resources and growth-fostering relationships on infertility stress in women. Journal of Mental Health Counseling, 24, 68-80. Goffman, E. (1963). Stigma: notes on the management of spoiled identity. New York: Simon and Schuster. Greil, A. L., Slauson-Blevins, K., & McQuillan, J. (2010). The experience of infertility: A review of recent literature. Sociology of Health & Illness, 32, 140-162. Greil, A. L. (1997). Infertility and Psychological Distress: A critical review of the literature. Social Science & Medicine, 45, 1679-1704. Lechner, L., Bolman, C., & van Dalen, A. (2007). Definite involuntary childlessness: Associations between coping, social support and psychological distress. Human Reproduction, 22, 288-294. Sociological Focus, 42, 394-416. Martins, M., Peterson, B., Almeida, V., & Costa, M. (2011). Direct and indirect effects of perceived soc-related stress. Medicine & Health, 26, 2113-2121. 11  McQuillan, J., Greil, A., Shreffler, K., & Bedrous, A. (2015). The importance of motherhood and fertility intentions among U.S. women. Sociological Perspectives, 58, 20-35. McQuillan, J., Greil, A., Shreffler, K., Wonch-Hill, P., Gentzler, K., & Hathcoat, J. (2012). Does the reason matter? Variations in childless concerns among U.S. women. Journal of Marriage and Family, 74, 1166-1181. McQuillan, J., Greil, A. L., Shreffler, K. M., & Tichenor, V. (2008). The importance of motherhood among women in the contemporary United States. Gender & Society, 22, 477-496. McQuillan, J., Stone, R. T., & Greil, A. L.  (2007). Infertility and life satisfaction among women.  Journal of Family Issues, 28, 955-981. through transition to first-time motherhood. Gender & Society, 21, 337-358.   Park, K. (2002). Stigma management among the voluntarily childless. Sociological Perspectives, 45, 21-45. Parry, S. (2005). Work, leisure and support groups: An examination of the ways women with infertility cope with pronatalist ideology. Sex Roles, 53, 337-346. (2007). The relationship between perceived stigma, disclosure patterns, support and distress in new attendees at an infertility clinic.  Human Reproduction, 22, 2309-2317. Men and Masculinities, 6, 330-348. Ulrich, M., & Weatherall, A. (2000). Motherhood and infertility: Viewing motherhood through the lens of infertility. Feminism & Psychology, 10, 323-336. Wegar, K. (2000). Adoption, family ideology, and social stigma: Bias in community attitudes, adoption research, and practice. Family Relations, 49, 363-369. Yap, M. (2002). Fertility and population policy: the Singapore experience. Journal of Population and Social Security (Population), supplement to Vol. 1, 643-65812  CHAPTER 1 Importance Placed on Motherhood oriFertility-Specific Distress? Introduction  Data from the National Survey of Family Growth suggested that 6.0%, or 1.5 million married women, in the U.S. were classified as infertile between June 2006 and June 2010 (Chandra et al., 2013). According to the medical definition, infertility is the inability to achieve pregnancy after one year of regular, unprotected heterosexual intercourse for those under the age of 35 and six months for those 35 and older (Chandra et al., 2013). Infertility is a distressing experience for those affected, particularly for women, because reproduction is subject to dominant social discourses about what it means to be a woman. Researchers have called the United States a  (Arendell, 2000; Loftus, 2009; McQuillan et al., 2015; Park, 2002; Ulrich & Weatherall, 2000). Although there are other avenues to becoming a mother, such as adoption, research suggests that social mores deem these avenues not on par with biological motherhood (Kline et al., 2006; Kressierer & Bryant, 1996). Thus, when infertility hinders e goal of reproduction she may experience decreased psychological wellbeing because of social stigma associated with the condition of infertility (Cousineau & Domar, 2007; McQuillan et al., 2007).   However, although fertility-specific distress may be, in many respects, a socially produced phenomenon linked to stigma, fertility-specific distress may also derive from the importance that an individual places on becoming a parent. Many women have indicated that motherhood is an important personal l13  that dream of motherhood is best realized through biological reproduction (McQuillan et al., 2008). Indeed, previous research has found evidence that couples who explicitly linked biological parenthood to happiness and life satisfaction were more likely to experience distress when faced with infertility, than were couples who did not explicitly link biological parenthood with happiness and life satisfaction (Brothers & Maddux, 2003).  Therefore, because fertility-specific distress may derive from both societal pressures and personal desires for children, I asked which of these, personal importance placed on motherhood or social stigma of infertility, was associated with greater fertility-specific distress? The following section provided an overview of the existing research on fertility-specific distress, including the most pertinent factors that influence this outcome and the remaining gaps in the literature. Literature Review Fertility-specific distress Researchers have linked infertility with fertility-specific distress for women in particular (Greil, 1997; Greil et al., 2010; Slade et al., 2007). Prior research has found that infertile women experience greater sensitivity, depression, hostility and anxiety compared to fertile women and that they experience these feelings at levels similar to those of women faced with cancer, heart disease, and HIV positive status (Cousineau & Domar, 2007). McQuillan and colleagues (2007) found that women who met the criteria for infertility (e.g. one year of unprotected intercourse without conception in their analysis) and perceived any bout of infertility in the course of their lifetime reported decreased life satisfaction compared to those who had not experienced a bout of infertility. In general, research has found that women tend to view infertility as a serious role 14  failure in life (Loftus, 2009). As the proceeding sections demonstrate, fertility-specific distress is linked to pronatalist social norms in the U.S., but may also be linked to the personal importance of motherhood.  Pronatalist social norms and the stigma of infertility Pronatalist social norms present in the U.S. and social messages arising from these norms contribute to fertility-specific distress (Arendell, 2000; Loftus, 2009; McQuillan et al., 2015; Park, 2002; Ulrich & Weatherall, 2000). Prior research has utilized various theories to explain this connection, including life course theories, identity theories (McQuillan et al., 2012) and the theory of stigma (Goffman, 1963; Miall, 1985). To guide this analysis, I relied on (1963) theory of stigma to understand infertility-related stigma. As Goffman (1963) explained, stigmcategorization of individuals based on attributes that are considered not in line with the normative social order. Social settings provide the background for which characteristics are deemed normative, and allow individuals within that social setting to categorize others without giving special thought or attention to the process. First appearances allow us to anticipate and classify others into socially defined categories that are engrained in our minds through repetitive interactions with others. These categories could include individual personality traits such as honesty, physical traits such as bodily ability, and structural traits such as occupation. These determinations about others are made without conscious reflection until someone falls outside the bounds of what is considered socially normative.  15  For example, if we encounter someone who, upon first inspection, is determined to possess an unfavorable trait that falls outside normative social boundaries, we will reduce that person in our minds to a discounted and tainted person, rather than a usual and whole person. This process of reduction is defined as stigma, and refers to an attribute that is deeply discrediting. Additionally, stigma does not always have to be visible in terms of a physical difference. In the case of infertility, the absence of children at a particular life stage (i.e. childbearing years) signals to others that a woman falls into a deviant category, since normative gendered expectations for women include biological motherhood. When a woman does not fulfill the expectation to bear and rear children during her childbearing years, society reduces her to a deviant and the woman bears stigmatization.  Infertility hinders the ability to bear biological children and the existing literature has provided several examples of stigma arising from the condition. Miall (1985) analyzed the experiences of infertile women and stigma framework. She discovered that a majority of the respondents in her study had experienced either negative or mixed reactions when revealing their infertility status to others, and that a majority had received unwanted questioning from others about their medical condition that made them  since the individuals with whom the infertile women interacted through their initial reactions and intrusive questioning. Other women were directly, and sometimes publicly, shamed or demonized for their childless status. One woman disclosed her infertility to her in-laws, who attempted to coerce her to divorce her husband (their son) so he could have children with a different woman who was able to reproduce; an adoptive mother was g experiences which had the effect of 16  making the adoptive mother feel like an outsider; and friends, family members, and strangers often reduced infertility maladjustment.   Less research has differentiated between the social and personal factors that may contribute to fertility-specific distress. However, McQuillan and colleagues (2012) provided an analysis that attempted to rectify the lack of research differentiating between the societal and personal level factors affecting fertility-related outcomes. Specifically, McQuillan and colleagues (2012) looked at messages from friends and family members to have children and the personal importance of motherhood to individual respondents and their mediating effects on childlesse pregnant, I feel McQuillan and colleauges conceptualized social pressures as messages from friends and family members to have children, and conceptualized the importance of motherhood as personal desires for children. Results suggested that the personal importance of motherhood significantly mediated the relationship between reasons for not having children and childlessness concerns, such that childless concerns rose with greater importance placed on motherhood. Social messages did not mediate this relationship, leading the authors to conclude that they did not find support for life course theory, which posits that normative social pressures have a strong effect on individuals when they do not meet certain benchmarks of adulthood, such as bearing children at a particular age.  Although it could be argued that I replicated the analysis by McQuillan and colleagues (2012) in this chapter, the outcome of this analysis (fertility-specific distress) is different from 17  childlessness concerns. I adopted this position because distress is different from merely expressing concern over a matter; research has suggested that fertility-specific distress is a unique outcome that has potentially catastrophic ramifications on mental health, such as anxiety and depression (Jacob et al., 2007; Greil et al., 2011; McQuillan et al., 2003; McQuillan et al., 2007; White & McQuillan, 2006). In fact, some analyses have primarily focused on fertility-specific distress, which has led to the development of specific scales to measure fertility-specific distress within the medical context (Glover et al., 1999). In contrast, researchers have described , around those who have children (McQuillan et al., 2012). Importance of motherhood Fertility-specific distress may also derive from the importance that an individual places on becoming a parent. Many women have indicated that motherhood is an important personal life goal for them, and that from their point of view, the dream of motherhood is best realized through biological reproduction (McQuillan et al., 2008). Indeed, previous research has found evidence that couples who explicitly linked biological motherhood to happiness and life satisfaction were more likely to experience distress when faced with infertility than couples who did not link biological motherhood with happiness or life satisfaction when similarly faced with infertility (Brothers & Maddux, 2003). Brothers and Maddux (2003) also found that those couples who ruminated more over having no children reported higher levels of distress than those couples who did not ruminate over having children, suggesting that rumination over the unfulfilled goal mediated the relationship between the goal of having a biological child and life satisfaction.  18  Furthermore, research in the field of pediatric cancer has explored the importance of motherhood to patients faced with the possibility of sterility following cancer treatment, a somewhat different, yet telling situation as to the importance of motherhood for many people starting from a young age. For example, in her meta-analysis of pediatric cancer research and fertility preservation, Schover (2009) found that 75% of young adult patients stated that having biological children in the future was a priority for them, and that patients who were unable to bear biological children in the future felt a great deal of distress.   Overall, what one may conclude from the research, is that infertility is both a personal and social experience. Many women desire to become biological mothers, yet this desire to procreate is entangled in normative expectations of femininity, as well as to stigma associated with lacking children. More importantly, it is difficult to disentangle personal desires to become a mother from pronatalist cultural norms that define birthing children as an essential part of appropriate femininity, thereby imbuing infertility with powerful stigma.  Aside from these two factorsthe stigma of infertility and the importance of motherhood to individual womenresearch has found that fertility-specific distress may vary by other factors. These factors were detailed in the sections below.  Intention to have a baby Although stigma has a powerful influence on fertility-related distress,  intention to have biological children may also influence her fertility-related distress. Some research has looked at the fact that an individual may not consider herself infertile, depending on her intention to have a baby. That is, a woman medical 19  professionals may define infertility in a particular way, but the process of defining infertility is a desire for children and how she defines her desires for biological children. Overall, prior research has found that women with the intention to have a baby have higher fertility-specific distress than women without the intention to have a baby when dealing with infertility, and that women with the intention to have a baby are more likely to identify as having a problem (Greil et al., 2016; Greil et al., 2011; Greil et al., 2010). Race/ethnicity and income Researchers have cited race/ethnicity as contributing to fertility-specific distress (Becker et al., 2006; Bell, 2009; Greil et al., 2016; Greil et al., 2011), with specific differences between low-income and higher- specific distress (Bell, 2009). Overall, Bell found that low-income women in her analysis felt as much distress as their higher-income counterparts, but that one factor greatly influencing poor  experiences of infertility was the overarching assumption that low-income women context. Because poor women are viewed as excessively fertile, they are placed outside of the infertility discourse, including the way they understand their diagnosis and the resolutions to their infertility.  Furthermore, in the U.S. Black women have historically been constructed as overly discourse about Black mothers (Bell, 2009; Sandelowksi & de Lacey, 2002) in contrast to white women, who are commonly portrayed as delaying childbearing in favor of career aspirations. Other research has found similar results for -fertility-specific distress, with a majority finding that Black women experience less distress than white 20  women and that Latinas experience similar levels to non-Latina white women (Greil et al., 2016; Greil et al., 2011; Jacob et al., 2007).  Society has also stereotyped Latinas leaving them outside of infertility discourse, similar to infertile Black women. Research has found that Latino couples experience distress associated with their infertility, but that these couples put specific emphasis on particular cultural ideals that may influence distress. For example, some researchers have argued that Latino men and women have a high level of familismo, or a high value placed on the family, thereby prompting a greater desire for children compared to white or Black families and leading to greater distress when dealing with infertility (Becker et al., 2006). Lending support to the pronatalist argument for Latinos, evidence has suggested that motherhood is considered an important life goal for Latinas and that motherhood is considered a vital part of gender identity and self-esteem; motherhood (and fatherhood) are the primary reasons for establishing a marriage; and that infertility places a great strain on relationships (Becker et al., 2006). Research has also found that distress is compounded for Latinas emphasis on alternative medicine, as well as an inability to communicate with medical professionals or lack of access to medical services (Nachtigall et al., 2009).  Employment status  Employment status is another important factor identified in the existing research (McQuillan et al., 2007). Prior analyses have shown that women with other sources of life fulfillment, such as a job, are at an advantage in terms of their ability to cope with infertility and may experience less distress when unable to bear a child than unemployed women (McQuillan et al., 2007). 21  McQuillan and colleagues (2007) found that employment ameliorated the negative effects of infertility on life satisfaction in their analysis of women living in the Midwest. This result only held for women who perceived a fertility problem, and not for those women in the study sample who did not perceive a fertility problem, despite trying to achieve pregnancy for twelve months or longer. Other research has found that women without employment outside of the home may struggle to redefine their status in light of the inability to conceive (Becker et al., 2006; McQuillan et al., 2003). In another analysis using a sample of women living in the Midwest, McQuillan and colleagues (2003) also found that employment was significantly associated with lower distress. Overall, roles outside of motherhood may ameliorate the effects of infertility on  Age  Age is another factor at the center of discussions associated with infertility, particularly within medical circles. Medical professionals have tended to warn women about the increase in infertility as age increases or the dangers of having a child when over the age of 35 (Andersen et al., 2000; Maheshwari et al., 2008). Large and influential organizations, such as the American Society for Reproductive Medicine (ASRM), have spearheaded national medical campaigns echoing concerns associated with advanced reproductive age (e.g. age 35 or older). For example, the ASRM introduced the campaign in 2001. This campaign warned women from waiting past the age of 35 to have a baby because of the increase in infertility, miscarriage, and potential fetal defects (Harter et al., 2005). Harter and colleagues argued that these types of campaigns represent the overarching public preoccupation with age-related infertility and the ways in which medical professionals exacerbate these beliefs. They also argued that age-related infertility (ARI) is one site fruitful for discourse about control of 22  , technology, and middle-class values associated with of how messages about age-related infertility are propagated, women may internalize concerns about age-related infertility, leading to increased distress.  Given the existing research on the strength of the pronatalist message in the context of infertility and the resulting psychological consequences, I posited that the stigma of infertility would have a stronger influence on fertility-specific distress than the importance of motherhood. I tested this hypothesis using the data and methods described in the following sections. Methods  Data  I utilized the National Survey of Fertility Barriers to conduct this analysis, which is comprised of data from a nationally-representative longitudinal survey, conducted between 2004 and 2007 and included 4,712 women ages 25-45 and a subsample of over 900 of their spouses/partners. I used Wave 1 only, which is publicly available via the Pennsylvania State University Simple Online Data Archive for Population Studies. In order to collect their data, the researchers utilized a random digital dialing sampling strategy using phone numbers purchased from Survey Sampling, Inc. The NSFB researchers included an oversampling of African American women and Latinas drawn from Census tracts with over 40% minority concentration.  23  For the purposes of this analysis, I included only those women who reported 12 months of unprotected intercourse without conception3. The final sample consisted of 1,151 women. There were also several sources of missing data in this analysis. Some of these missing data derived from the planned missing design of the data set; the strategy of the NSFB was to randomly assign two-thirds of cases to each scale item in the data set (McQuillan et al., 2012). Data missing due to nonresponse was handled using full information maximum likelihood estimation in Mplus version 10 (Muthén & Muthén, 1998-2011).  Measures Outcome. The primary outcome of interest was fertility-specific distress. Researchers read respondents who reported having unprotected intercourse for at least 12 consecutive months control without getting pregnant, please tell me if you had the following reactions when you , or never to the following five woman, where a higher score indicated greater distress. This scale had a Cronbach Independent variable. Importance of motherhood was a scale variable representing personal valuation of motherhood. Researchers asked respondents to reply to the following four items on a Likert-type scale ranging from strongly agree to strongly disagree: 1)                                                            3 The NSFB considered 12 months of unprotected intercourse the marker for women to meet the definition of infertility, rather than the medical definition which differentiates between women 35 years of age and older and those under age 35.  24  ving kids is important to me feeling like a This scale ranged from 4 to 16, with higher scores representing a greater importance placed on motherhood. The Cronbach Independent variable. The stigma of infertility was a scale variable representing y. Researchers asked respondents to reply to the following three items on a Likert-type scale ranging from strongly This scale ranged from 3 to 12, with higher scores representing a greater level of stigma. The Cronbach, indicating good reliability.   Covariates. Other variables utilized in this analysis included the following. Employment status was a series of dummy variables. I retained the original coding for employed full time and employed part time, and recoded all other categories (e.g. in school, unemployed, keeping house, disabled, and others) to represent a not working variable. Age was a continuous variable ranging from 25 to 45. . For marital status I recoded married and cohabiting variable. I also combined divorced, widowed, and separated. Finally, I retained the original dummy variable representing the  for those respondents who stated that they were never married. Never married was the reference category. Race/ethnicity was a series of dummy variables, including white, Black and Latino respondents. I considered white respondents the reference category. I recoded all of these variables to create discrete categories, with first preference given to Latino respondents followed by Black and white respondents. Family income 25  ranged from 1 to 12, and categories ranged from 0=no income to 12=$100,000 or more per year. I recoded this variable into a dummy, whereby 0=below $40,000 per year and 1=$40,000 per year and above. I selected this coding because the category of $40,000-$49,999 was the median point of family income in the sample. Finally, intention to have a baby was a dummy variable, do you intend to have a baby? whereby 0=do not intend to have a baby and 1=intend to have a baby. Analytic strategy To evaluate the effects of importance of motherhood and the stigma of infertility on fertility-specific distress, I performed multiple linear regressions using Mplus. In the first model, I included the two primary independent variables and intention to have a baby. I added the covariates of age, race/ethnicity, employment status, family income, and marital status in the second model. Results  Descriptive statistics Table 1 presented the descriptive details of the sample in the current study. Nearly half of the sample was comprised of whites (46%), followed by Black (28%) and Latina respondents (18%). Over half of the sample was married (61%) and approximately equal numbers of respondents were divorced/widowed/separated (20%) or never married (19%). Similarly, over half of the sample was employed full time (54%), followed by the not working (32%). The fewest respondents were employed part time (13%) and the mean age of the sample was over 35. Furthermore, over half of the sample (54%) reported having an annual family income of $40,000 or more. A small portion of the sample (16%) reported having intentions to get pregnant. 26  Respondents reported a mean of 8.08 (SD=1.40) for the stigma of infertility scale and a mean of 13.09 (SD=2.10) for the importance of motherhood scale, suggesting that women placed a high importance on motherhood and also believed that a relatively high level of stigma also exists within society towards infertile women. Finally, the general fertility-specific distress level of the sample was low (.59). Table 1.  Descriptive Statistics for the Sample for Analysis of Importance of Motherhood and Stigma of Infertility on Fertility-specific Distress Variable n M  SD Race/ethnicity     White 531 .46 .50 Black 329 .28 .45 Latina 209 .18 .38 Marital status    Married/cohabiting  702 .61 .49 Divorced/widowed/separated 228 .20 .40 Never married 220 .19 .39 Employment status     Employed full time 618 .54 .50 Employed part time 149 .13 .33 Not working 365 .32 .47 Family income 1050 .55 .50 Age 1151 35.76 5.87 Intention to have a baby 184 .16 1.52 Independent variables    Stigma of infertility 1126 8.08 1.40 Importance of motherhood 1126 13.09 2.10 Dependent variables    Fertility-specific distress 970 .59 .97   In turning to the descriptive statistics by race/ethnic group in Table 2, results suggested that the majority of white respondents were married (74%), employed full-time (52%), and had an approximate mean age of 36.5. Furthermore, 65% made above $40,000 annual family income and 15% stated a positive intention to have a baby. White women also stated the highest level of fertility-specific distress (.61) compared to Blacks (.54) and Latinas (.55). 27  Table 2. Descriptive Statistics for White Respondents Only Variable n M  SD Marital status    Married/cohabiting  530 .74 .44 Divorced/widowed/separated 530 .18 .38 Never married  530 .08 .28 Employment status     Employed full time 531 .52 .50 Employed part time 531 .15 .36 Not working 531 .33 .47 Family income 531 .65 .48 Age 531 36.57 5.79 Intention to have a baby 476 .15 .35 Independent variables    Stigma of infertility 526 8.07 1.31 Importance of motherhood 526 13.55 1.91 Dependent variables    Fertility-specific distress 461 .61 .99   In comparison in Table 3, the majority of Black respondents were never married (40%), were employed full time (64%), and had a mean age of 36. Only 42% of respondents made above $40,000 annual family income, but 19% stated a positive intention to have a baby. Black respondents also indicated a higher level of stigma (8.22) than whites (8.07); a lower level of importance placed on motherhood (12.61 compared to 13.55) compared to whites; and lower fertility-related distress compared to whites (.54 compared to .61).          28  Table 3. Descriptive Statistics for Black Respondents Only Variable N M  SD Marital status    Married/cohabiting  329 .34 .48 Divorced/widowed/separated 329 .26 .44 Never married  329 .40 .49 Employment status     Employed full time 329 .64 .48 Employed part time 329 .09 .28 Not working 329 .28 .45 Family income 301 .42 .49 Age 329 36.00 5.87 Intention to have a baby 329 .19 .39 Independent variables    Stigma of infertility 321 8.22 1.54 Importance of motherhood 321 12.61 2.29 Dependent variables    Fertility-specific distress 283 .54 .97   Finally, in Table 4 the majority of Latina respondents were married (70%), but approximately equal percentages were employed full-time (42%) or not working (43%). The mean age for Latinas in the sample was approximately 34, making them younger on average than whites (mean age of 36.5) or Black respondents (mean age of 36). However, 21% stated a positive intention to have a baby, which was a larger percentage than both Black (19%) and white respondents (15%). In terms of income, 46% of respondents made above $40,000 annual family income, which was higher than the percentage of Blacks (42%) but lower than the percentage of whites (65%). Latinas also stated a lower level of stigma (7.85) than whites (8.07) and Blacks (8.22); a lower level of importance of motherhood compared to whites (12.67 compared to 13.55) but not Blacks (12.61); and higher distress (.55) compared to Blacks (.54), but not whites (.61).   29  Table 4. Descriptive Statistics for Latina Respondents Only Variable N M  SD Marital status    Married/cohabiting  209 .70 .46 Divorced/widowed/separated 209 .15 .36 Never married  209 .44 .50 Employment status     Employed full time 209 .42 .49 Employed part time 209 .15 .36 Not working 209 .43 .50 Family income 176 .46 .50 Age 209 33.86 5.65 Intention to have a baby 200 .21 .41 Independent variables    Stigma of infertility 199 7.85 1.40 Importance of motherhood 199 12.67 1.93 Dependent variables    Fertility-specific distress 157 .55 .94   Overall, a larger percentage of white respondents were married and older, on average, compared to Blacks and Latinas. Black women represented the largest percentage of those working full time and the never married. Latinas represented the youngest group, on average, compared to Blacks and whites and were equally represented in the never married and married categories. Latinas also represented the group with the highest percentage of respondents with a positive intention to have a baby compared to Blacks and whites. Black respondents appeared to experience the highest level of stigma compared to whites and Latinas, but had the lowest importance placed on motherhood and the lowest level of fertility-specific distress. White women also had the highest level of fertility-specific distress compared to Blacks and Latinas. In general, the majority of the sample did not indicate a high level of fertility-specific distress when broken down by race/ethnic groups.  30  Regression results In turning to the results of the regression models presented in Table 5, Model I showed positive and significant results for the stigma of infertility on fertility-specific distress; every one unit increase in the stigma of infertility scale was associated with a .05 increase in fertility-specific distress. Intention to have a baby and importance of motherhood were not significantly associated with fertility-specific distress. Model II showed significant positive results between fertility-specific distress and two key variables: the stigma of infertility and intention to have a baby. Specifically, an intention to have a baby was associated with a .21 increase in fertility-specific distress for infertile individuals. The stigma of infertility was associated with a .05 increase in fertility-specific distress for each one unit increase in the scale. No other variables were significantly associated with fertility-specific distress.   In summary, the stigma of infertility was positively and significantly associated with fertility-specific distress in Models I and II. Similarly, intention to have a baby was positively and significantly associated with fertility-specific distress in Model II. No other variables were found to be significant.          31  Table 5. Regression Models for the Importance of Motherhood and Stigma of Infertility on Fertility-specific Distress Variable  Distress  Model I Model II  Stigma of infertility  .05(.03)* .05(.03)* Importance of motherhood  .02(.01) .01(.01) Intention to have a baby  .17(.10) .21(.10)* Family income  -.02(.01) Age   .00(.01) Race/ethnicity    White (reference category)   Black  -.06(.08) Latino  -.08(.09) Relationship status   Never married (reference category)   Married/cohabiting  .12(.09) Widowed/divorced/separated  .10(.10) Employment status   Unemployed (reference category)    Employed full-time  -.08(.07) Employed part-time  .12(.11) *p<.05; **p<.01; ***p<.001; n=1,151 Discussion and Conclusion  My primary aim in this study was to take into account the social stigma of infertility and the personal importance of motherhood and to test their association with fertility-specific distress, while also taking into account other important factors discussed in the literature. However, before venturing into a discussion of the results, it was important to consider the descriptive statistics for the sample and the possible explanations for my findings. Several possible explanations exist within the literature that could help to explain the descriptive statistics of the sample. First, white women cited the highest level of fertility-specific distress compared to Latinas and Black women. This finding supported prior scholarship that has supported the notion that Black women experience lower distress than whites or Latinas (Greil et al., 2016; Greil et al., 2011; Jacob et al., 2007). The finding for fertility-specific distress could also be explained by 32  the fact that the white women in the sample were older, on average, than both Latinas and Black women. As Harter and colleagues (2005) argued, medical professionals and societies (e.g. American Society for Reproductive Medicine) commonly warn about the dangers of childbearing within the advanced reproductive years. Specifically, childbearing over the age of 35 is associated with a higher risk of infertility, miscarriage/stillbirth, and fetal abnormalities (Andersen et al., 2000; Maheshwari et al., 2008).  Given that the definition of advanced maternal age is 35 years and older, it is difficult to fully conclude that higher average age was the reason why white women in the sample experienced higher fertility-specific distress than Black women, since the average age for Black women was 36 compared to 36.5 for white women. Nevertheless, prior research on age-related inferti-specific distress since the average age for Latinas in the sample was 34. Black women also stated the lowest level of fertility-specific distress compared to Latinas and whites, which may be associated with the fact that Black women represented the largest percentage of the full-time employed. As prior research has shown, employment can ameliorate the negative effects of infertility by providing an alternative source of fulfillment for women facing the disease (McQuillan et al., 2007). Furthermore, in considering the higher stigma for Black respondents compared to whites Specifically, Bell found that non-Interestingly, a larger percentage of Black women stated a positive intention to have a baby -33  white women are subjected to stereotypes that characterize them as overly fertile and outside of the realm of infertility discourse, Black women have intentions to become pregnant even though they are commonly prohibited from entering into discussions about infertility and its solutions. Similarly, Latinas represented the largest group in the sample that stated a positive intention to have a baby. This finding associated with social stereotypes about non-white women. However, cultural ideals that emphasize family (e.g. familismointention to have a baby since childbearing is considered an important life goal for Latinas, in particular (Becker et al., 2006). Latinas also represented the largest percentage of the not working compared to white and Black women, which may have resulted in motherhood as more of a primary role than other roles, such as participation in the paid labor force. Thus, if motherhood intention to have a baby and bear a biological child to fulfill this goal. Finally, white women had the highest importance placed on motherhood compared to Latinas and Black women. In contrast, Black women had the lowest importance placed on motherhood compared to whites and Latinas. Prior research could help to partially explain these findings for Latinas. For example, prior research has suggested that Latino/as highly value motherhood (Becker et al., 2006), but it is difficult to know why whites cited a higher importance of motherhood compared to both Latinas and Black women, or why Black women cited the lowest importance of motherhood. Perhaps Black women placed a low importance on nd a psychological internalization of these messages that would  34  In turning to the results for the regression models, the results provided some interesting insights into the possible mechanisms, from both a structural and individual psychological viewpoint, that relate to fertility-specific distress amongst women. Specifically, I found support for the association between the stigma of infertility and fertility-specific distress, but I did not find support for the association between the importance of motherhood and fertility-specific distress in either of the models. These findings lent support to the notion that stigma is a powerful social influence within the context of infertility. That is, although women may place a great deal of personal importance on becoming a mother, the stigma of not bearing biological children had a stronger association with fertility-specific distress than the importance of motherhood. Cthis was an expected finding that stigma plays a significant role in reactions to a deviation from normative social expectations for behavior. In this case, the inability to bear a biological child was the deviation from normative and gendered social expectations for women. Thus, when a woman did not meet this expectation, she was more likely to experience fertility-specific distress than those women who met normative social expectations to bear biological children.   It is also important to note that none of the covariates in the regression models were significantly associated with fertility-specific distress. These findings do not diminish the fact that other research has found support for the significant influence of age, race/ethnicity, and other factors on fertility-specific distress. One of the drawbacks of the current research was that the sample was primarily comprised of married women over the age of 35. In addition, most of the women in the sample (regardless of race/ethnicity) were working full-time and had a family income of $40,000 or more per year. Perhaps a more diverse sample in terms of marital status, age, and family income would result in more significant results for fertility-specific distress.   35  There were other limitations to the present analysis. Specifically, the data were cross-sectional because this analysis only used Wave I of the NSFB, thereby limiting understanding of the causal nature of relationships between the independent and dependent variables. Additionally, the sample indicated a generally low level of fertility-specific distress, which failed to fully capture the serious impact of infertility on mental well-being cited in prior research (Jacob et al., 2007; Greil et al., 2011; McQuillan et al., 2003; McQuillan et al., 2007; White & McQuillan, 2006). Pintentions into trying/not trying, as this analysis did, may be problematic, since women who are -specific distress when they do not become pregnant. experiences (Greil et al., 2011). I was not able to include multiple categories of intention to have a baby because of small cell size for some of the categories. In addition, because such a small percentage of women stated a positive intention to get pregnant in the sample overall (16%), this likely affected the results, leading to no significant findings for intention to have a baby and its association with fertility-specific distress. Finally, the measure of stigma I used in this analysis was limited for several reasons. people whonly included three items to measure the construct. Other research has posited that stigma is best measured using multiple dimensions. Specifically, Bresnahan and Zhuang (2011) found support for five dimensions of stigma (i.e, labeling, negative attribution, separation, status loss, and controllability) using the maximum likelihood method of factor extraction out of the 105 36  possible dimensions mentioned in prior research to measure stigma. As with any secondary data analysis, the variables utilized in the study did not directly measure the particular research questions presented in this chapter. Despite these limitations, this analysis offered two major contributions. First, it included both the structural and individual levels in the context of infertility. The second major contribution was the finding that the stigma of infertility was associated with fertility-specific distress, lendded further insight into and support for the role of stigma in the context of infertility. Although other research has found evidence that stigma plays a powerful role in the experiences of women within the reproductive years, no other research has considered both the structural and individual levels in tandem (Blyth & Moore, 2001; Miall, 1985; Remennick, 2000). Overall, this analysis added empirical evidence t about the power of stigma in the context of infertility, while also taking into account that psychological factors play a role in determining fertility-related attitudes.  Future research would benefit from further interrogation of these two factors and their relation to fertility-specific distress. The importance of motherhood and the stigma of infertility are both potential sites for fertility-specific distress. Although it is difficult to disentangle the individual and structural levels, it is nevertheless an important task that may help mental health or medical professionals to understand and alleviate negative infertility outcomes such as fertility-specific distress. Finally, a better measure of stigma utilizing the five dimensions posited by Bresnahan and Zhuang (2011) would provide a more nuanced understanding of the concept of stigma.  37  Because the consequences of fertility-specific distress are so great, including serious depression and a feeling of complete life failure when biological reproduction is not achieved, it is vital to fully investigate and interrogate the mechanisms influencing this outcome. Some preliminary steps could include better public education on infertility, including the emotional responses it elicits from those who are diagnosed as infertile, their partners, and their family and friends. 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Introduction Infertility, medically defined as the inability of a woman to achieve pregnancy after one year of unprotected intercourse for those under 35, and six months for those 35 and older, is a distressing experience for those affected (Chandra et al., 2013). Research has established that biological reproduction is linked to notions of what it means to be a woman, which can lead to fertility-specific distress when women are faced with infertility (Arendell, 2000; Loftus, 2009; McQuillan et al., 2015). Women also tend to cite infertility as a cataclysmic role failure (Loftus, 2009). Infertility is also commonly attributed to a woman in a heterosexual partnership, regardless of which partner may have a medical problem preventing conception (Greil et al., 1988). In general, research has found that fertility-specific distress is a serious concern for women (Greil, 1997).  Wom responses to infertility are tied to pronatalist social norms present in the U.S. that emphasize that bearing biological children is crucial to fulfilling a feminine identity. The earing and rearing of children to the qualities of nurturance and self-sacrifice, both of which are equated with socially normative expectations of femininity. Thus, when a woman is unable to bear children, this may cause feelings of distress because of the associated social stigma of failing to abide by pronatalist norms (Blyth & Moore, 2001; Miall, 1985). These feelings can be as extreme as those experienced when facing a cancer diagnosis, HIV positive status, or heart disease (Cousineau & Domar, 2007).  43  Women may also place a great deal of importance on becoming a parent, deriving from their own desires, and separate from the social pressures to bear biological children. Although it is difficult to separate the influence of societal norms in shaping individual expectations for motherhood , there is evidence to suggest that some women do not desire children (Park, 2002) lending support to the idea that not every woman is affected by social expectations in the same way or places the same importance on motherhood. Other research has investigated the personal importance of motherhood in interviews with long-term infertile couples, people who spent long periods of time reflecting on their desire for children. These couples identified the benefits that they would receive from having a child, such as happiness, increased well-being, social control, and continuity (van Balen & Trimbos-Kemper, 1995). Furthermore, the couples identified happiness and increased well-being as the top two reasons for wanting children, suggesting a highly internalized personal desire for children that would result in emotions linked to individual satisfaction (van Balen & Trimbos-Kemper, 1995).  Despite the power of pronatalist norms in influencing fertility-specific distress and the personal importance that many individuals place on becoming a parent, social support is important to alleviating fertility-specific distress (Gibson & Myers, 2002; Lechner et al., 2006; Martins et al., 2011). Prior research has identified social support as a critical component of how women adjust to the stressors of infertility, particularly because they are more likely than men to disclose their status to others (Martins et al., 2011). Overall, the National Survey of Family Growth estimated that approximately 6.0%, or 1.5 million married U.S. women, were infertile between 2006 and 2010 (Chandra et al., 2013). Given that many women are affected by infertility and may experience distress, the role of social support is an important topic in need of 44  exploration. Thus, in this chapter I aimed to interrogate the moderating potential of social support on the relation between the importance of motherhood and the stigma of infertility to fertility-specific distress.  Literature Review Fertility-specific distress It is well established that infertility is associated with increased distress, especially for women (Greil, 1997; Greil et al., 2010; Slade et al., 2007). Historically, researchers have failed to fully understand fertility-specific distress because of the tendency to view it as a problem of individual women presenting for medical treatment within clinical settings. The tendency of researchers to focus on infertile women within medical settings has tended to exclude infertile women who do not present for medical treatment, and has also prevented the development of a comprehensive view of infertile women as social actors existing within a pronatalist culture within research on infertility. Ultimately, when viewed solely as patients with a medical condition in need of remedy, infertile individuals are left outside the scope of discussions that extend beyond the medical context and into the larger social world. Greil (1997) argued that this view of the infertile as patients rather than social actors has led to several limitations in research on fertility-specific distress, including heavy reliance on convenience samples from clinical settings. Women from clinical settings represent a narrow group (Bell, 2009; Martins et al., 2011) since only 50% of U.S. women diagnosed with infertility ever seek treatment (Chandra et al., 2013). If fertility-specific distress is studied only using samples from clinical venues, research will be limited in its ability to generate knowledge about women who do not utilize fertility treatment within clinical settings. Furthermore, relying on clinical samples makes it difficult to fully 45  understand whether the distress these patients experience is a result of their infertility or the  (1997) review, more research has remedied this problem using large scale national datasets collected using non-convenience sampling methods outside of the medical setting (Greil et al., 2010; Greil et al., 2011).  Overall, as Greil and colleagues (2011) stated, the existing research tends to be dichotomized into that which focuses on medical service delivery and the need for psychological counseling on one hand, and ethnographic approaches meant to understand the experience of infertility within the sociocultural context, on the other hand. The National Survey of Fertility Barriers is one data set that has offered a resolution to the problem of divergent study aims; the NSFB incorporated psychological variables targeting s psychological responses to infertility such as fertility-specific distress or confidence in biomedicine; variables targeted at gaining insight into the medical aspects of infertility such as medical intervention use; and sociodemographic variables common to quantitative data sets such as age, race/ethnicity and marital status. Because the NSFB incorporated many variables targeted at the different facets of the infertility experience, it is a unique data set able to target typically divergent study aims. Social support Fertility-specific distress is a serious problem, but scholars have identified social support as a possible mechanism to reduce the negative effects of stress (Gibson & Myers, 2002; Lechner et al., 2006; Martins et al., 2011), including the psychological ramifications. Scholars have defined social support 46  include talking to others such as friends or a mental health professional, joining an online infertility support group or a face-to-face infertility support group sponsored by a local hospital or fertility clinic, letting emotions out, or discussing the problem with religious mentors (Martins et al., 2011; Malik & Coulson, 2008; 2010; 2011; Slade et al., 2007). Prior research has established that social support aids in accelerated recovery from illness or disease in general (Cobb, 1976; Wortman & Conway, 1985). Social support also has the capacity to act as a buffer for life stressors and improves individual wellbeing (Cohen & Wills, 1985). Evidence has shown that social support is crucial when faced with a medical illness or health challenge, and that it can lead to improved health outcomes (Almeida et al., 2009; Gallant, 2003). The efficacy of social support also applies to infertility, whereby affected individuals have the potential to experience the same types of health benefits from social support, as do those with other chronic illnesses or diseases (Gibson & Myers, 2002; Lechner et al., 2006). In fact, previous research has found evidence to suggest that social support lessens fertility-specific distress among women (Gibson & Myers, 2002; Lechner et al., 2006; Martins et al., 2011)4.  Pronatalism and the stigma of infertility Some researchers have focused on pronatalism and its relationship to wfertility-specific distress (Greil et al., 2010; McQuillan et al., 2011). Greil and colleagues (2010) argued that all societies are pronatalist, but that some value motherhood as a primary identity for women more so than others. Although the U.S. may not be the strongest in terms of pronatalism, compared to to procreate is strongly linked to social and economic                                                            4 Research on social support has also explored other factors such as willingness to disclose infertile status (Slade et al., 2007), negative coping mechanisms and their influence on the availability of social swith these sources (Malik & Coulson, 2008). 47  wellbeing (Remmnick, 2000), biological motherhood is still revered as a privileged status for women that represents dominant social norms of femininity. Not abiding to these standards can lead to stigma, including unwanted questioning about when someone plans to have children, pressure by family members or spouses to have children, or outright demonizing of women who cannot bear or do not desire children (Miall, 1985; McQuillan et al., 2012).  Goffman posited the theory of stigma (1963), whereby he defined stigma as a phenomenon that occurs when individuals within society categorize others based on attributes that are considered in line with the normative social order. Social settings provide the context for which characteristics are deemed normative, and allow individuals within that social setting to categorize others without giving special thought or attention to the process. First appearances allow us to anticipate and classify others into socially defined categories that are engrained in our minds through repetitive interactions with others. These categories could include individual personality traits such as honesty, physical traits such as bodily ability, and structural traits such as occupation. These determinations about others are made without conscious reflection until someone falls outside the bounds of what is considered socially normative. For example, if we encounter someone who, upon first inspection, is determined to possess a less than desirable trait that falls outside normative social boundaries, we will begin to reduce that person in our minds to less than a usual and whole person, to a discounted and tainted one. This process is defined as stigma, and refers to an attribute that is deeply discrediting. Additionally, stigma does not always have to be visible in terms of a physical difference on the body. In the case of infertility, the absence of children at a particular life stage (e.g. childbearing years) signals to others that a woman falls into a deviant category, since normative gendered expectations for women include biological motherhood. When a woman does not fulfill this expectation during 48  her childbearing years by bearing and raising biological children, she is deemed deviant and thereby stigmatized. ory of stigma to a myriad of illnesses and other social conditions, including infertility, and found evidence to suggest that stigma influences fertility-specific distress (see Remmenick, 2000).  Although prior research has established a link between the stigma of infertility and distress (Remmenick, 2000), the relationship between the stigma of infertility and the presence of social support has remained unclear. Some research has provided a preliminary glance into the potential relationship by highlighting the stigma associated with disclosing an infertile status to others (Slade et al., 2007). Consequently, social support is not always a given for infertile women because of the stigma surrounding infertility and the reluctance that they may experience in disclosing their status to outsiders. The experience of stigma when disclosing an infertile status may overshadow the potential social support someone may acquire through sharing their struggles (Miall, 1985; Slade et al, 2007).  For example, Slade and colleagues (2007) analyzed 87 women and 64 men attending an infertility clinic and found that perceptions of stigma were negatively associated with social support. Although social support was negatively associated with anxiety, depression, and overall infertility distress for both men and women, disclosure of infertility was not directly linked to social support. Furthermore, women perceived greater stigma associated with their infertile status, although they had higher disclosure to people within their social support systems compared to men. igher disclosure to people within their social support systems was associated with higher generic distress. Regardless of disclosure level, stigma was associated with lower social support perceptions for both men and women. Notably, the authors argued that stigma should be considered when advocating social support in the context of 49  infertility and that this may be particularly applicable in the case of women. These findings lend support to the notion that stigma is a powerful force. Specifically, stigma has the capacity to compound  fertility distress when others react negatively to her disclosure of her struggles with the condition. Overall, since prior research has identified social support as a crucial resource in ameliorating distress associated with disease (Gibson and Meyers, 2002; Lechner et al., 2006), it was imperative to consider if social support moderated the relation between the stigma of infertility and fertility-specific distress, which was my primary aim in this analysis.   Importance of motherhood Although stigma plays a powerful role in creating fertility-specific distress, distress may also derive from the personal importance that an individual places on becoming a parent. Many women have indicated that motherhood is an important personal life goal for them, and that this dream is best realized through biological reproduction, from their point of view (McQuillan et al., 2008). Indeed, previous research has found evidence that couples who explicitly linked biological motherhood to happiness and life satisfaction were more likely to experience distress when faced with infertility (Brothers & Maddux, 2003). Furthermore, research in the field of pediatric cancer has explored the importance of motherhood to patients faced with the possibility of sterility following treatment, a somewhat different, yet telling situation as to the importance of motherhood for many people starting from a young age. For example, Schover (2009) found in her meta-analysis of pediatric cancer research on fertility preservation that 75% of young adult patients stated that having biological children in the future was a priority for them, and that patients who were unable to bear biological children in the future felt a great deal of distress.  50  However, similar to the lack of research linking the stigma of infertility to social support seeking, the potential link between the importance of motherhood and social support is also unclear. In this analysis, I posited that it is important to consider both the importance that a woman may place on becoming a mother, as well as the stigma she may experience because of her infertile status, in attempting to understand the role of social support and its relation to fertility-specific distress.  Intention to have a baby An important consideration in research on infertility is taking individual definitions of infertility into account, rather than merely relying upon the medical definition to differentiate the fertile from the infertile. For example, prior research has found that there are women who meet the medical definition of infertility, but do not consider themselves infertile because they are not trying to achieve pregnancy (Greil et al., 2010). That is, someone may al., 2011). Some research has differentiated between these groups of women and found differences in distress, with higher distress associated with a higher level of intention to become pregnant (Greil et al., 2011, Jacob et al., 2007). However, no research exists that focuses on the potential relationship between intentions to become pregnant and the presence of social support. In this analysis, I posited that it may be that those with higher intentions to become pregnant would have more social support for their infertility, as they are more likely to acknowledge that they meet the definition of infertile than someone who states that they are to seek and have the social support in dealing with it. 51  Sociodemographic characteristics   Prior research has deemed several sociodemographic factors important when discussing stigma and fertility-specific distress. Some of these factors include age, race/ethnicity, income and employment status (Bell, 2009; Greil et al., 2011; Sandelowksi & de Lacey, 2002). In the following sections, I addressed the potential connection between each of these variables and social support.  Race/ethnicity and income In regards to race/ethnicity and income, previous research has argued that non-white and poor reproductive abilities, and thereby placed outside of infertility discourse (Bell, 2009; Sandelowksi & de Lacey, 2002). In contrast, white and higher-income women are commonly portrayed as having to deal with infertility as a result of delayed childbearing to pursue career aspirations. Regardless of overarching stereotypes surrounding poor and non-white individuals, research has shown that poor and non-white women are still affected by pronatalist norms and face the struggle of infertility (Bell, 2009).  For example, in he sample consisted of poor women who expressed sincere desires for children but typically reported that medical treatments, the primary method of remedying infertility, were  that other methods of becoming a mother (such as adoption) were also out of reach because of structural loopholes. In general, research has supported the notion that poor and non-white women are subject to two dominant, but opposing, social discourses surrounding gender: 1) the discourse of mandatory motherhood and the related stigma that comes with the inability to fulfill this goal through biological reproduction 52  and 2) the specific social belief that poor and non-white should not become mothers in the first place (Bell, 2009; Sandelowksi & de Lacey, 2002).  -white and poor women and their infertility. In their analysis of Latino couples utilizing a low-income infertility clinic, Becker and colleagues (2006) also found evidence that having children was a highly desirable goal. These couples believed having children was the primary basis for forming a relationship, and felt great strain in their relationship when they were unable to have biological children. Reproduction was also cited as a primary source of self-esteem and gender identity for Latino couples.  Latino respondents are commonly excluded from mainstream discourse surrounding infertility. For example, the scope of the existing  (Becker et al., 2006; Nachtigall et al., 2009). Some of the factors that hinder Latinos in medical settings include the inability to afford treatments, language barriers, and cultural differences between patients and doctors (Becker et al., 2006; Nachtigall et al., 2009). In addition, the existing research on Latino infertility has utilized samples from low-income clinical settings, in particular (Becker et al., 2006). Researchers have also tended to focus on the higher rates of Latino fertility compared to whites, thereby perpetuating stereotypes about Latino   No research exists that specifically focuses on the availability of social support for non-white or low-income women in the context of infertility. Instead, research has tended to focus on non-white and low-income  (i.e., the studies mentioned in the preceding section) rather than their use of friendships, family, or other sources 53  of social support. Overall, very little is known about non-white and low-income experiences of fertility-specific distress, as well as the presence of social support systems in non-white and low-income  are commonly left outside discourse about infertility.  Employment status Prior research has identified efertility-specific distress (McQuillan et al., 2007). Employment is one source of fulfillment for women unable to bear biological children, with some research arguing that it has an ameliorating effect on distress (McQuillan et al., 2003; McQuillan et al., 2007). In contrast, women without employment may struggle to redefine their identity in light of their infertility and inability to produce biological children (Becker et al., 2006; McQuillan et al., 2003). It is unclear how employment status may be associated with social support, but because of its relationship to distress in prior research, it is incorporated in this analysis.  Age Advanced maternal age is a central topic in discussions associated with infertility. Medical professionals have defined advanced maternal age as bearing children over the age of 35 (Andersen et al., 2000; Maheshwari et al., 2008) and have raised concerns about the dangers of attempting to have a child during these reproductive years because of the increased risk for infertility, miscarriage, or birth defects be reproductive capacity (Harter et al., 2005) over the age of 35. Some scholars have challenged this viewpoint: for example, Harter and colleagues argued that the notion of advanced maternal age represents an overarching public preoccupation with age-related infertility. Harter and colleagues also posited 54  that medical professionals exacerbate the public preoccupation with age-related infertility because they are interested in remedying this disease through medical means and thereby generating more business. Overall, Harter and colleagues argued that advanced maternal age is one site fruitful for discourse about control of wowomen through discourse about time, technology and middle-class values associated with taking  through costly and potentially painful artificial reproductive technologies. Regardless of how messages about age-related infertility are propagated, it is a real medical concern (Andersen et al., 2000; Maheshwari et al., 2008). In this analysis, I posited that it may also be that older women would have more social support for their condition than younger women because of the emphasis placed on age-related infertility; older they are at the end of their fertility lifecycle; and a heightened level of urgency associated with their fertility.   Given the prior research on social support, in this analysis I argued that social support would moderate the relationship between the stigma of infertility and fertility-specific distress. I also argued that social support would affect the relationship between the importance of motherhood and fertility-specific distress. Methods Data I utilized the National Survey of Fertility Barriers to conduct this analysis, which is comprised of data from a nationally-representative longitudinal survey that was conducted by researchers from several universities between 2004 and 2007 and included 4,712 women ages 25-45 and a subsample of over 900 of their spouses/partners. I utilized Wave I for this analysis, which is 55  publicly available via the Pennsylvania State University Simple Online Data Archive for Population Studies. In order to collect their data, the researchers utilized a random digital dialing sampling strategy using phone numbers purchased from Survey Sampling, Inc. An oversampling of African American women and Latinas from Census tracts with over 40% minority concentration.  For the purposes of this analysis, I only included those women who reported 12 months of unprotected intercourse without conception5. The final sample consisted of 1,151 women. There were also several sources of missing data in this analysis. Some of this missing data derived from the planned missing design of the data set; the strategy of the NSFB was to randomly assign two-thirds of cases to each scale item in the data set (McQuillan et al., 2012). I handled data missing due to nonresponse using full information maximum likelihood estimation in Mplus version 10 (Muthén & Muthén, 1998-2011).  Measures Outcome. The primary outcome of interest was fertility-specific distress. Researchers read the following statement to respondents who reported having unprotected intercourse for at control without getting pregnant, please tell me if you had the following reactions when you y, or never to the following five 3                                                           5 The NSFB considered 12 months of unprotected intercourse the marker for women to meet the medical definition of infertility. 56  woman, where a higher score indicated greater distress.  This scale had a Cronbach Independent variable. Importance of motherhood was a scale variable representing . Researchers asked respondents to reply to the following four items on a Likert-type scale ranging from strongly agree to strongly disagree: 1) This scale ranged from 4 to 16, with higher scores representing a greater importance placed on motherhood. The Cronbach Independent variable. Stigma of infertility was a scale variable. Researchers asked respondents to reply to the following three items on a Likert-type scale ranging from strongly agree to strongly disaThis scale ranged from 3 to 12, with higher scores representing a greater level of stigma. The Cronbach Moderating variable. Social support was a scale variable. Researchers asked respondents to indicate their level of agreement with the following four items, with possible responses ranging from strongly agree to strongly disagree: 1) 2) 3) 4) 57  degree of perceived social support. The Cronbach.83, indicating good reliability. Covariates. Other variables utilized in this analysis included the following. Employment status was a series of dummy variables. I retained employed full time and employed part time with their original coding, and recoded all other categories (e.g. disabled, in school, unemployed, keeping house and other) to represent a not working variable. Age was a continuous variable ranging from 25 to 45. For marital status I recoded married and cohabiting to create a union variable. I also combined divorced, widowed, and separated. Finally, I retained the original dummy variable representing the never married for those respondents who stated that they were never married. Never married was the reference category. Race/ethnicity was a series of dummy variables, including white, Black and Latino respondents. I considered white respondents the reference category and recoded to create discrete categories, with first preference given to Latino respondents followed by Black and white respondents. Family income ranged from 1 to 12, and categories ranged from 0=no income to 12=$100,000 or more per year. I recoded this variable into a dummy, whereby 0=below $40,000 per year and 1=$40,000 per year and above. I selected this coding because the category of $40,000-$49,999 was the median point of family income in the sample. Finally, intention to have a baby was a dummy variable, whereby do you intend to have a baby? whereby 0=do not intend to have a baby and 1=intend to have a baby. Analytic strategy To evaluate the effects of importance of motherhood and the stigma of infertility on fertility-specific distress while taking into account the moderating potential of social support, I performed 58  multiple linear regressions using Mplus. In the first model, I included the two primary independent variables, intention to have a baby, the covariates, and the main effect of social support. I added the interactions between importance of motherhood and social support and stigma of infertility and social support in the second model.  Results  Descriptive statistics Table 6 presented the descriptive details of the sample in the current study. Nearly half of the sample was comprised of whites (46%), followed by Black (28%) and Latino respondents (18%). Over half of the sample was married (61%) and approximately equal numbers of respondents were divorced/widowed/separated (20%) or never married (19%). Similarly, over half of the sample was employed full time (54%), followed by the not working (32%). The fewest respondents were employed part time (13%) and the mean age of the sample was over 35. Over half of the sample reported an annual family income of $40,000 or more. A small portion of the sample (16%) reported having intentions to get pregnant.  Respondents reported a mean of 8.08 (SD=1.40) for the stigma of infertility scale and a mean of 13.09 (SD=2.10) for the importance of motherhood scale, suggesting that women placed a high importance on motherhood but also believed that a relatively high level of stigma also exists within society towards infertile women. Respondents also reported a mean of 14.15 for the social support scale (SD=2.47), suggesting that women in the sample felt that they had high levels of social support. In general, the sample also indicated a low level of fertility-specific distress (.59). 59  Table 6.  Descriptive Statistics for the Sample for Social Support, the Importance of Motherhood, and the Stigma of Infertility on Fertility-specific Distress Variable N M  SD Race/ethnicity     White 531 .46 .50 Black 329 .28 .45 Latino 209 .18 .38 Marital status    Married/cohabiting  702 .61 .49 Divorced/widowed/separated 228 .20 .40 Never married  220 .19 .39 Employment status     Employed full time 618 .54 .50 Employed part time 149 .13 .33 Not working 365 .32 .47 Family income 1050 7.60 3.08 Age 1151 35.76 5.87 Intention to have a baby 184 .16 1.52 Independent variables    Stigma of infertility 1126 8.08 1.40 Importance of motherhood 1126 13.09 2.10 Moderating variable    Social support 1141 14.12 2.88   In turning to the descriptive statistics by race/ethnic group, results presented in Table 7 suggested that the majority of white respondents were married (74%), employed full-time (52%), and had an approximate mean age of 36.5. Furthermore, 65% made above $40,000 annual family income and 15% stated a positive intention to have a baby. White women also had the highest level of fertility-specific distress (.61) compared to Blacks (.54) and Latinas (.55) but the highest level of social support (14.59) compared to Blacks (14.00) and Latinas (13.31).      60  Table 7. Descriptive Statistics for White Respondents Only Variable N M  SD Marital status    Married/cohabiting  530 .74 .44 Divorced/widowed/separated 530 .18 .38 Never married  530 .08 .28 Employment status     Employed full time 531 .52 .50 Employed part time 531 .15 .36 Not working 531 .33 .47 Family income 531 .65 .48 Age 531 36.57 5.79 Intention to have a baby 476 .15 .35 Independent variables    Stigma of infertility 526 8.07 1.31 Importance of motherhood 526 13.55 1.91 Social support 526 14.59 2.11 Dependent variables    Fertility-specific distress 461 .61 .99   In comparison in Table 8, the majority of Black respondents were never married (40%), were employed full time (64%), and had a mean age of 36. Only 42% of respondents made above $40,000 annual family income, but 19% stated a positive intention to have a baby. Black respondents also indicated a higher level of stigma (8.22) than whites (8.07); a lower level of importance placed on motherhood (12.61 compared to 13.55) compared to whites; and lower fertility-related distress compared to whites (.54 compared to .61).         61  Table 8. Descriptive Statistics for Black Respondents Only Variable N M  SD Marital status    Married/cohabiting  329 .34 .48 Divorced/widowed/separated 329 .26 .44 Never married  329 .40 .49 Employment status     Employed full time 329 .64 .48 Employed part time 329 .09 .28 Not working 329 .28 .45 Family income 301 .42 .49 Age 329 36.00 5.87 Intention to have a baby 329 .19 .39 Independent variables    Stigma of infertility 321 8.22 1.54 Importance of motherhood 321 12.61 2.29 Social support 321 14.00 2.52 Dependent variables    Fertility-specific distress 283 .54 .97   Finally in Table 9, the majority of Latina respondents were married (70%), but approximately equal percentages were employed full-time (42%) or not working (43%). The mean age for Latinas in the sample was approximately 34, making them younger on average than whites (mean age of 36.5) or Black respondents (mean age of 36). However, 21% stated a positive intention to have a baby, which was a larger percentage than both Black (19%) and white respondents (15%). In terms of income, 46% of respondents made above $40,000 annual family income, which was higher than the percentage of Blacks (42%) but lower than the percentage of whites (65%). Latinas also stated a lower level of stigma (7.85) than whites (8.07) and Blacks (8.22); a lower level of importance of motherhood compared to whites (12.67 compared to 13.55) but not Blacks (12.61); and higher distress (.55) compared to Blacks (.54), but not whites (.61). Latinas also had the lowest level of social support (13.31) compared to both Blacks (14.00) and whites (14.59). 62  Table 9. Descriptive Statistics for Latina Respondents Only Variable N M  SD Marital status    Married/cohabiting  209 .70 .46 Divorced/widowed/separated 209 .15 .36 Never married  209 .44 .50 Employment status     Employed full time 209 .42 .49 Employed part time 209 .15 .36 Not working 209 .43 .50 Family income 176 .46 .50 Age 209 33.86 5.65 Intention to have a baby 200 .21 .41 Independent variables    Stigma of infertility 199 7.85 1.40 Importance of motherhood 199 12.67 1.93 Social support 199 13.31 2.96 Dependent variables    Fertility-specific distress 157 .55 .94   Overall, a larger percentage of white respondents were married and older, on average, compared to Blacks and Latinas. Black women represented the largest percentage of those working full time and the never married. Latinas represented the youngest group, on average, compared to Blacks and whites and were equally represented in the never married and married categories. Latinas also represented the group with the highest percentage of respondents with a positive intention to have a baby compared to Blacks and whites, but the lowest level of social support. Black respondents appeared to experience the highest level of stigma compared to whites and Latinas, but had the lowest importance placed on motherhood and the lowest level of fertility-specific distress. White women also had the highest level of fertility-specific distress compared to Blacks and Latinas, but had the highest level of social support. In general, the majority of the sample did not indicate a high level of fertility-specific distress when broken down by race/ethnic groups. 63  Regression model results In turning to the results for the first model presented in Table 10, my results suggested that the main effect of social support on fertility-specific distress was negatively and significantly associated with fertility-specific distress, whereby a one unit increase in social support was associated with a .04 decrease in fertility-specific distress. The stigma of infertility was positively and significantly associated with fertility-specific distress, while the importance of motherhood was not significantly associated to fertility-specific distress. Specifically, every one unit increase in the stigma of infertility was associated with a .05 increase in fertility-specific distress.  Model II presented the results of the moderating effect of social support between the stigma of infertility and the importance of motherhood and fertility-specific distress. The results included in Model II suggested that social support did not moderate the relationship between either the stigma of infertility or the importance of motherhood on fertility-specific distress and instead acted as a mediator, whereby all significance disappeared for these variables.  Other significant covariates included intention to have a baby, which was positively and significantly associated with fertility-specific distress in Model II. Specifically, in Model II, intention to have a baby was associated with a .23 increase in fertility-specific distress. Employment statuses (e.g. employed full-time and employed part-time) were the only sociodemographic variables significantly associated with fertility-specific distress. In both Models I and II, full-time employment was associated with a .54 increase in fertility-specific distress compared to not working status and part-time employment was associated with a .13 increase in fertility-specific distress compared to not working status. 64  To summarize, social support was negatively associated with fertility-specific distress in Model I, while the stigma of infertility was positively associated with fertility-specific distress. However, I did not find any significant relationships between the independent and dependent variables when I incorporated social support as a moderator. The findings did not lend support to either hypothesis posited in this analysis, but revealed that social support instead operated as a mediator between the stigma of infertility and fertility-specific distress such that the main effects for these variables disappeared. Other significant covariates included intention to have a baby, which was positively and significantly associated with fertility-specific distress, and full-time and part-time employment status, which were both positively and significantly associated with fertility-specific distress compared to not working status.               65  Table 10. Regression Models for Social Support, the Stigma of Infertility and the Importance of motherhood on Fertility-specific Distress  Variable                               Fertility-Specific Distress  Model I Model II  Stigma of infertility  .05(.02)* .18(.13) Importance of motherhood  .01(.01) -.02(.08)  Social support  -.04(.01)** .00(.01) Social support*stigma of infertility  --- -.01(.01) Social support*importance of motherhood --- .00(.01) Family income  -.05(.07) -.05(.07) Intention to have a baby .23(.10)* .23(.10)* Age  .00(.01) .00(.01) Race/ethnicity    White (reference category)   Black -.07(.08) -.07(.08) Latino -.08(.09) -.08(.09) Relationship status   Never married (reference category)   Married/cohabiting .13(.09) .13(.09) Widowed/divorced/separated .11(.10) .12(.10) Employment status   Unemployed (reference category)    Employed full-time .54(.01)*** .54(.02)*** Employed part-time .13(.01)*** .13(.01)*** ***p<.001; **p<.01; *p<.05; n=1,151 Discussion and Conclusion My primary aim in this study was to determine if social support moderated the relationship between the stigma of infertility and fertility-specific distress and the importance of motherhood and fertility-specific distress. However, prior to embarking on a discussion of the results, it was important to consider the possible explanations for the descriptive statistics of the sample.  66  First, white women cited the highest level of fertility-specific distress compared to Latinas and Black women. This finding supported prior scholarship that has supported the notion that Black women experience lower distress than whites or Latinas (Greil et al., 2016; Greil et al., 2011; Jacob et al., 2007). The finding for fertility-specific distress could also be explained by the fact that the white women in the sample were older, on average, than both Latinas and Black women. As Harter and colleagues (2005) argued, medical professionals and societies (e.g. American Society for Reproductive Medicine) commonly warn about the dangers of childbearing within the advanced reproductive years. Specifically, childbearing over the age of 35 is associated with a higher risk of infertility, miscarriage/stillbirth, and fetal abnormalities (Andersen et al., 2000; Maheshwari et al., 2008).  Given that the definition of advanced maternal age is 35 years and older, it is difficult to fully conclude that this was the reason why white women in the sample experienced higher fertility-specific distress than Black women, since the average age for Black women was 36 compared to 36.5 for white women. Nevertheless, prior research on age-related infertility could -specific distress since the average age for Latinas in the sample was 34. Black women also stated the lowest level of fertility-specific distress compared to Latinas and whites, which may be associated with the fact that Black women represented the largest percentage of the full-time employed. As prior research has shown, employment can ameliorate the negative effects of infertility by providing an alternative source of fulfillment for women facing the disease (McQuillan et al., 2007). Furthermore, in considering the higher stigma for Black respondents compared to whites Specifically, Bell found that non-67  Interestingly, a larger percentage of Black women stated a positive intention to have a baby -white women are subjected to stereotypes that characterize them as overly fertile and outside of the realm of infertility discourse, Black women have intentions to become pregnant even though they are commonly prohibited from entering into discussions about infertility and its solutions. Similarly, Latinas represented the largest group in the sample that stated a positive intention to have a baby. This associated with social stereotypes about non-white women. However, cultural ideals that emphasize family (e.g. familismointention to have a baby since childbearing is considered an important life goal for Latinas, in particular (Becker et al., 2006). Latinas also represented the largest percentage of the not working compared to white and Black women, which may have resulted in motherhood as more of a primary role than other roles, such as participation in the paid labor force. Thus, if motherhood intention to have a baby and bear a biological child to fulfill this goal. White women had the highest importance placed on motherhood compared to Latinas and Black women. In contrast, Black women had the lowest importance placed on motherhood compared to whites and Latinas. The findings for Latinas could be partially explained by prior research that has suggested that Latino/as highly value motherhood (Becker et al., 2006), but it is difficult to know why whites cited a higher importance of motherhood compared to both Latinas and Black women or why Black women cited the lowest importance of motherhood. Perhaps Black women placed a low importance on motherhood because of the stereotypes surrounding 68  internali Finally, white women had the highest social support, followed by Blacks, and then Latinas. It is unclear why white women had the highest level of social support, although it may be that white women are better able to access sources of social support via the Internet (Malik & Coulson, 2008; 2010) compared to Black women and Latinas. Conversely, Latinas may have the lowest level of social support because they may not want to discuss their infertility with others. Specifically, because of the high importance of family posited to exist within the cultural value of familismo (Becker et al., 2006), Latinas may feel a sense of shame if they cannot meet this important cultural expectation. social support to cultural factors without further exploration in future research. In turning to the findings of the regression models, results suggested that social support may not be as influential in moderating the relationship between either of these factors and fertility-specific distress. Although prior research has found some evidence for the importance of social support when facing infertility, the moderating relationship of social support between social stigma or personal importance placed on motherhood and fertility-specific distress remains unclear. However, social support on its own was significant, lending weight to prior research findings that it does reduce negative outcomes such as fertility-specific distress. Given these results, it may be beneficial to consider the type of social support offered, infertile ; variations in these may result in different levels of fertility-specific distress in the context of stigma. For example, Lechner and colleagues (2006) found a relationship between passive coping style and 69  dissatisfaction with social support amongst involuntarily childless couples. A passive coping style was defined as withdrawal from external contacts and general avoidance of the problem rather than active social support seeking. It is important to note that this type of coping may be associated with the stigma of infertility, since embarrassment about the problem associated with the stigma of the condition may lead someone to withdraw, rather than actively confront the problem. Additionally, someone who places a high value on motherhood, but is infertile, may also avoid discussing the problem because of the pain associated with doing so. Although Lechner and colleagues (2006) point out that their study was unique in that it focused on indefinitely childless couples rather than those actively dealing with infertility, they also provide evidence as to the importance of receiving social support, but that couples should also actively seek it.  In terms of the method of gaining social support, a large body of research has focused on improving dramatically over the past twenty years, online forums have become more common. Malik and Coulson (2008; 2010; 2011) have dedicated a substantial amount of research to investigating the use of this particular medium of potential social support and have found mixed results. Two studies found positive outcomes for this coping mechanism (Malik and Coulson, 2008). Themes emerging from experiences with infertility and to provide information, advice, gratitude, friendship, and chit-Coulson, 2008).  70  The Internet may also provide a sense of anonymity not afforded by in-person forms of social support, which is an important consideration for those who feel a great deal of stigma because of their infertile status. However, a later study by Malik and Coulson (2010) found that there were several negative aspects to using the Internet for social support, including reading about negative experiences and  Reading about other  associated with a heightened sense of stigma because a woman realizes she is not meeting societal expectations in comparison to other women. Similarly, a woman who deeply desires children, but cannot realize her dream, may experience great pain over readi  Additionally, a few covariates were significant in this analysis, including intention to have a baby and employment status. This points to the need for continued research on which factors may whether or not a woman has social support, since research is currently limited in its knowledge in this area. Intention to have a baby has been identified as an important factor influencing outcomes such as distress (Greil et al., 2010), so this was an expected finding. However, that this finding remained significant in the context of social support is a contribution to the existing research. Intention to have a baby clearly plays a significant role in determining responses to infertility. For example, intention to have a baby may be associated with fertility-. Specifically, if a woman deeply desires a child and is not able to conceive within 12 months of unprotected intercourse (or 6 months if she is age 35 or older), she is more likely to notice that she meets the medical definition of infertility compared to a woman who is not intending to become pregnant. Hence, her fertility-specific distress may rise because she is aware that it is taking longer than the specified norm for her to conceive a much wanted child.  71  Furthermore, the findings for employment status were also interesting in light of prior research that has suggested that employment has an ameliorating effect on fertility-specific distress (McQuillan et al., 2003; McQuillan et al., 2007). Specifically, I found that both full-time and part-time employment status were positively associated with fertility-specific distress regardless of the presence of social support. It could be that occupation is a better measure of alternative sources of satisfaction for women struggling with infertility, rather than mere employment in any sort of job.  Overall, there were some limitations of this research. First, the sample was primarily comprised of married women over the age of 35. In addition, most of the women in the sample (regardless of race/ethnicity) were working full-time and had a family income of $40,000 or more per year. Perhaps a more diverse sample in terms of marital status, age, and family income would result in more significant results for the moderating effect of social support on the relation between the importance of motherhood and the stigma of infertility to fertility-specific distress. The sample also indicated a generally low level of fertility-specific distress, which failed to fully capture the serious impact of infertility on mental well-being cited in prior research (Jacob et al., 2007; Greil et al., 2011; McQuillan et al., 2003; McQuillan et al., 2007; White & McQuillan, 2006). Thirdly, I relied on cross sectional data (Wave 1 only). Future research would do well to incorporate multiple waves of the NSFB data, since prior research has called for the analysis of the fertility experience across time (Greil, 1997). Prior research has altrying/not trying may be problematic, as this analysis didfertility-specific distress when they do not become pregnant. Incorporating multin 72  the context of social support (Greil et al., 2011). I was not able to include multiple categories of intention to have a baby because of small cell size for some of the categories.  Finally, the measure of stigma I used in this analysis is limited for several reasons. people who have a hard time getting pregnant find it  Additionally, the measure of stigma I used in this analysis was limited for several reasons. First, the measure of stigma was aimed at garnering respeople personal experiences of stigma. Second, the measure of stigma in the NSFB only included three items to measure the construct. Other research has posited that stigma is best measured using multiple dimensions. Bresnahan and Zhuang (2010) found support for five dimensions of stigma (i.e. labeling, negative attribution, separation, status loss, and controllability) using the maximum likelihood method of factor extraction out of the 105 possible dimensions mentioned in prior research to measure stigma. Future research would do well to include a more nuanced measure of stigma. As with any secondary data analyses, the variables utilized in the study did not directly measure the particular research questions presented in the chapter. Overall, more research needs to be conducted on social support, taking into account the powerful role of the stigma of infertility, while also attending to the diversity of individuals facing the condition.  73  REFERENCES   74  REFERENCES  Almeida, J., Molnar B., Kawachi, I, & Subramanian, S. (2009). Ethnicity and nativity status as determinants of perceived Social Support: Testing the ConSocial Science & Medicine, 68, 1852-1858.  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Pediatric Blood & Cancer, 53, 281-284. relationship between perceived stigma, disclosure patterns, support and distress in new attendees at an infertility clinic.  Human Reproduction, 22, 2309-2317. Van Balen, F., & Trimbos-Kemper, T. (1995). Involuntarily childless couples: Their desire to have children and their motives. Journal of Psychosomatic Obstetrics and Gynecology, 16, 137-144. White, L. & McQuillan, J. (2006). No longer intending: The relationship between relinquished fertility intentions and distress. Journal of Marriage & Family, 68, 478-490. 77  Wortman, C., & Conway, T. (1985). The role of social support in adaptation and recovery from physical illness. San Diego, CA: Academic Press.     78   CHAPTER 3  Social Stigma of Infertility and Importance Placed on Motherhood: Does Either Influence Faith in Medical Interventions in the Context of Infertility? Introduction  Medical professionals have defined infertility as the inability to achieve pregnancy after one year of unprotected intercourse for women under the age of 35, and six months for women age 35 and older (Chandra et al., 2013). As an abundance of research has established, infertility is a particularly distressing experience and this is especially true for women (Cousineau & Domar, 2007; McQuillan et al., 2003; White & McQuillan, 2006). Research has linked pronatalist social McQuillan et al., 2015; Park, 2002; Ulrich & Weatherall, 2000). That is, although infertility is often thought of as a private experience, predominant social expectations exist that deem childbearing crucial childless women as unenviable social aberrations (Becker & Nachtigall, 1994). Those who choose to remain childless in the face of infertility are viewed as selfish and as less caring than women with children (Mcquillan et al., 2012). Nevertheless, women may also deeply desire biological children separate from social pressures to become a biological parent. For example, some research has argued that desires for biological children are nearly universal and that women, in particular, show lower mental health compared to men when these desires go unmet (Chachamovich et al., 2010).  79  Medical intervention is one recourse to the infertility dilemma, regardless of whether someone is driven to reproduce because of social pressures or personal desires to bear biological children. Prior research has shown that biomedicine has a powerful influence in the west, in particular, because of prevailing social beliefs in its ability to remedy any physical ailments and illnesses (Becker, 2000). This is also true for infertility, which medical professionals have deemed a disease6. In fact, infertile women may place greater faith in medicine to remedy their infertility compared to fertile women (Johnson & Simon, 2012). In considering prior research, in this chapter I aimed to decipher what factors may confidence in biomedicine for infertility and contribute to the scant body of research that currently exists in this area. Specifically, given pronatalist norms, I sought to understand whether the stigma of infertility was associated with s confidence in biomedicine for infertility and compared this to the personal importance that women may place on becoming a parent and the potential relation to their confidence in biomedicine. No other research exists that attempts to understand how the social structure and/or individual psychology prompt women toward biological childbearing, and whether either of these levels is associated with confidence in biomedicine. Thus, I took Gprimary basis to understand the social stigma associated with infertility, and also took into social-structural and the individual psychological, and that these may be associated with faith in medicine to remedy infertility.                                                             6 Some scholars have taken issue with the notion of infertility as medical disease, instead arguing achieve conception within a particular stage of life and within a certain span of time (Becker, 2000). 80  Literature Review Pronatalism and the stigma of infertility (1963) theory of stigma  usual person to a tcategorization of individuals based on attributes that are considered in line with the normative social order. Social settings provide the context for which characteristics are deemed normative, and allow individuals within that social setting to categorize others without giving special thought or attention to the process. First appearances allow us to anticipate and classify others into socially defined categories that are engrained in our minds through repetitive interactions with others. These categories could include individual personality traits such as honesty, physical traits such as bodily ability, and structural traits such as occupation. These determinations about others are made without conscious reflection until someone falls outside the bounds of what is considered socially normative.  For example, if we encounter someone who, upon first inspection, is determined to possess a less than desirable trait that falls outside normative social boundaries, we will begin to reduce that person in our minds to less than a usual and whole person, to a discounted and tainted one. This process is defined as stigma, and refers to an attribute that is deeply discrediting. Additionally, stigma does not always have to be visible in terms of a physical difference. In the case of infertility, the absence of children at a particular life stage (e.g., childbearing years) signals to others that a woman falls into a deviant category since normative gendered expectations for women include biological motherhood. When a woman does not fulfill 81  this expectation during her childbearing years by bearing and raising biological children, she is deemed deviant and thereby stigmatized. Although Goffman emphasized bodily signs associated with physical disability indicating deviation from social normality, some scholars have extended his theory , yet stigmatized conditions, such as infertility (Riessman, 2000). Park (2002) found that infertile individuals faced stigma from friends and family members who questioned them about when they plan to have children when the infertile individual had not disclosed their infertile status. Similarly, Park also found that if infertile respondents had disclosed their status, in-laws sometimes insisted that they grant their spouse a divorce because of the infertility.  Currently, the research does not provide insight into how stigma may influence confidence in biomedicine, leaving this as an area ripe for exploration. Some research has provided preliminary evidence into the influence of personal attitudes and their relation to confidence in biomedicine, which is detailed in the following section (see Johnson & Simon, 2012). However, the existing research has failed to differentiate between attitudes towards biological motherhood that derive from internal dialogues (e.g. personal importance of motherhood) and those that derive from structural pressures (e.g. stigma of infertility) and how these relate to confidence in biomedicine.  Importance of motherhood As the prior section eluded, personal values surrounding reproduction may also influence reactions to infertility, including how much confidence one places in biomedicine to resolve the problem. Prior research has not found significant results to support the link between the importance of motherhood and fertility-specific distress (i.e., Chapter 1 of this dissertation) but 82  other research has looked at how personal values influence attitudes toward biomedicine, specifically, and found significant results. For example, Johnson & Simon (2012) found that women who cited motherhood as personally important had high confidence in biomedicine. valuation of reproduction. They found support that this variable was positively and significantly associated with confidence in biomedicine, but did not differentiate between this personal measure and the larger social structural factors at play, such as stigma. Johnson & Simon are the only scholars to interrogate the relation between the importance of motherhood and confidence in biomedicine. Again, it is important to consider the importance of motherhood in the present analysis because of the underexplored nature of the relationship between the importance of motherhood and confidence in biomedicine, including a comparison with the stigma of infertility and its potential relation to confidence in biomedicine.  Overall, research is scant in this area as to how values associated with reproduction may influence confidence in biomedicine, and no research exists comparing how social influence, such as stigma, may influence confidence in biomedicine compared to personal values associated with reproduction. The literature has provided some direction in terms of revealing who has access to fertility treatments, who actually uses treatment, and who believes they have access to treatment. Because no other research exists that has specifically focused on confidence in biomedicine, I drew upon the existing research in these three areas. Specifically, I selected the covariates used in this analysis based on the existing research associated with access to fertility treatments, actual use of fertility treatments, and belief in the ability to access treatments. First, knowing who has access to treatments was important to consider in order to uncover the factors associated with the use of biomedicine for infertility. Second, it was important to consider 83  attitudes about the ability to access fertility treatments because it is an attitudinal measure, similar to confidence in biomedicine. In general, I assumed that access to fertility treatments, actual use of fertility treatments, and attitudes about the ability to access fertility treatments would be associated with confidence in biomedicine.  Use and access to infertility treatment When considering confidence in biomedicine, it was first important to know who uses medical treatment since use of biomedicine for infertility is likely associated with attitudes toward fertility treatment in general. Prior research has found evidence that women who utilize fertility treatment tend to be older, married, college graduates, and have higher income than their respective counterparts (Chandra et al., 2013; White & McQuillan, 2006). However, in turning to who has access to treatments, research has found that the number of women who are classified as infertile by medical professionals is larger than the number that are actually able to access treatment. Again, women that have the ability to access treatment are largely white, middle-class, and highly educated (Jain, 2006).  Prior research has found that one of the reasons that white women are able to access medical treatment for infertility is because they are viewed as rightly deserving of motherhood (Bell, 2009). As the following sections show, the metanarrative surrounding infertility is divided along racial/ethnic and class-based lines that designate who is considered infertile, as well as who should be allowed to pursue medical treatment for infertility, and how these women negotiate their infertility as a result.   84  Race/ethnicity, income, and employment status Racial/ethnic minority and low-income women are generally barred from accessing infertility treatment (Bell, 2009; Sandelowski, 1994) and this may affect their attitude towards biomedicine. For example, Bell (2009) found that low-income women experienced more difficulty than higher-income women in getting appointments, affording treatment, or taking time off from work to attend appointments, procedures, or treatments. Overall, the women in reported that  . Bell argued that low-income women were unable to access treatment and had the attitude that medical interventions were because medical professionals and society, at large, tend to portray poor and non-white women as  and therefore not in need of medical assistance for infertility. Instead, society views non-whitas a problem in need of control. Indeed, some not pursue medical treatment for their infertility because they felt that doctors would diminish their desires for pregnancy because of their race/ethnicity. These women relied upon other forms -biological children within their social networks or adopting stepchildren (Collins, 1987).  Other research has found that non-white individuals have difficulty in accessing treatment, place higher faith in alternative medicine to achieve conception, and have a lower confidence in biomedicine compared to whites. For example, Becker and colleagues (2006) analyzed a group of Latino couples utilizing a low-income infertility clinic and found that these couples had high desires for children and cited children as they primary reason for establishing a marriage. These couples were unable to afford infertility treatments beyond a basic level because of low income, which was closely linked to their employment status, with women as 85  homemakers and men as the primary wage earner. Women did not want to be labeled as medically signified a lack of hope. Many of the women in the study also reported having undergone reproductive massage to achieve conception, as well as consuming herbal teas for infertility.  Similarly, Nachtigall and colleagues (2009) analyzed a sample of primarily Spanish-speaking Latino couples utilizing a low-income infertility clinic. These couples also highly valued children and said they would continue attempting pregnancy until physically unable. In addition, the researchers found that respondents had a particularly difficult time interacting and communicating with medical staff and doctors at the clinic because of language and cultural barriers. Cultural trong beliefs in alternative medicine (e.g., herbal remedies, specialized massages to induce reproductive functioning) and a lack of tion in general. In combination, these two factors led to difficult and unfruitful conversations between doctors and patients. These conversations often resulted in a greater reliance on non-biomedical remedies to treat infertility. Overall, previous research has supported the notion that the use of biomedicine to treat infertility is largely a higher income, pursuit, or that medical professionals would like to limit medical assistance to wealthier white women. White and higher income women also tend to have greater faith in its eventual success in helping them to conceive, compared to poor and non-white women (Becker et al., 2006; Bell, 2009; Nachtigall, 2009; Sandelowski, 1994).  Age Age is an area in which medical professionals are able to reinforce predominant notions about who should use infertility treatment and who can most benefit. The American Society for 86  draw attention to the increase in lateity.  However, as Harter and colleagues (2005) argued, this campaign represents the overarching public preoccupation with age-related infertility and the ways in which this is exacerbated by medical professionals. Other research published within medical journals has also demonstrated -related infertility, or the dangers of having a child over the age of 35 (Andersen et al., 2000; Maheshwari et al., 2008). Overall, medical professionals and public health campaigns present biomedicine infertility, or at the very least, a requirement to increase the chances of conception during the ability to have a (healthy) biological child is viewed as tenuous, at best (Harter et al., 2005). Because of the emphasis on biomedicine to remedy infertility, and public health campaigns that help to spread the message of the dangers of having a child during the advanced reproductive years, older women may place a higher confidence in biomedicine than younger women. Intention to have a baby Individuals must also realize they have a medical condition, such as infertility, to prompt the formation of particular attitudes including confidence in biomedicine. For example, if an individual perceives a health condition as immediately threatening to their well-being, they are more likely to seek solutions. Overall, this suggests that it is important to take note of the significance that individuals attach to their health. White and colleagues (2006) found that couples were more likely to seek help if they perceived a fertility problem, which extended beyond meeting the medical definition of infertility (in this case, one year of regular, unprotected intercourse). Similarly, Greil and McQuillan (2004) found that women who reported trying to 87  conceive were more likely to seek help to have a baby. However, intention to have a baby was not always associated with seeking out medical assistance, or having confidence in biomedicine to help achieve this goal. As the prior section demonstrates, cultural beliefs along race/ethnic lines or stereotypes about non-white and poor women may also influence confidence in biomedicine (Becker et al., 2006; Nachtigall et al., 2009).  Given the previous research on confidence in biomedicine (Johnson & Simon, 2012) and in other areas associated with infertility treatment use (White & McQuillan, 2006) and accessibility (Bell, 2009), I posited that the stigma of infertility would have a greater relation to confidence in biomedicine compared to the importance of motherhood because of the strength of stigma in creating individual attitudes and behaviors.   Methods Data I utilized the National Survey of Fertility Barriers to conduct this analysis, which is comprised of data from a nationally-representative longitudinal survey. Researchers from several universities collected the between 2004 and 2007. The data included 4,712 women ages 25-45 and a subsample of over 900 of their spouses/partners. I utilized Wave 1 for this analysis, which is publicly available via the Pennsylvania State University Simple Online Data Archive for Population Studies. In order to collect their data, the researchers utilized a random digital dialing sampling strategy using phone numbers purchased from Survey Sampling, Inc. In addition, the researchers collected an oversampling of African American women and Latinas from Census tracts with over 40% minority concentration.  88  For the purposes of this analysis, I included only those women who reported 12 months of unprotected intercourse without conception7. The final sample consisted of 1,151 women. There were also several sources of missing data in this analysis. Some of these missing data derived from the planned missing design of the data set; the strategy of the NSFB was to randomly assign two-thirds of cases to each scale item in the data set (McQuillan et al., 2012). Data missing due to nonresponse was handled using full information maximum likelihood estimation in Mplus version 10 (Muthén & Muthén, 1998-2011).  Measures Outcome. The outcome of interest was a scale variable measuring womenconfidence in biomedicine to remedy infertility, which was comprised of three items: 1) edical science can 2) 3) women can wait until their late 30s to have a baby and This scale ranged from 5 to 12, with higher scores representing a greater confidence in biomedicine. The Cronbach  Independent variable. Importance of motherhood was a scale variable representing , whereby respondents were asked to reply to the following four items on a Likert-type scale ranging from strongly agree to strongly disagree: 1)                                                            7 The NSFB considered 12 months of unprotected intercourse the marker for women to meet the medical definition of infertility. 89  This scale ranged from 4 to 16, with higher scores representing a greater importance placed on motherhood. The Cronbach Independent variable. The stigma of infertility was a scale variable representing asked to reply to the following three items on a Likert-type scale ranging from strongly agree to  ranged from 3 to 12, with higher scores representing a greater level of stigma. The CronbachAlpha was .74, indicating good reliability.   Covariates. Other variables utilized in this analysis included the following. Employment status was a series of dummy variables. I retained the original coding for employed full time and employed part time, and recoded all other categories (e.g. keeping house, not working, in school, disabled, and other) to represent a not working variable. Age was a continuous variable ranging from 25 to 45. . For marital status I recoded married and cohabiting I also combined divorced, widowed, and separated. Finally, I retained the original dummy variable representing the  for those respondents who stated that they were never married. I considered never married the reference category. Race/ethnicity consisted of a series of dummy variables, including white, Black and Latino respondents. In considered white respondents the reference category. I recoded all variables to create discrete categories, with first preference given to Latino respondents followed by Black, and lastly, white respondents. Family income ranged from 1 to 12, and categories ranged from 0=no income to 12=$100,000 or more per year. I recoded this variable into a dummy, whereby 0=below $40,000 per year and 90  1=$40,000 per year and above. I selected this coding because the category of $40,000-$49,999 was the median point of family income in the sample. Finally, intention to have a baby was a do you intend to have a baby? whereby 0=do not intend to have a baby and 1=intend to have a baby.  Analytic strategy To evaluate the effects of importance of motherhood and the stigma of infertility on confidence in biomedicine, I performed multiple linear regressions using Mplus. In the first model, I included only the primary independent variables of importance of motherhood and stigma of infertility. In the second model, I incorporated all other covariates including age, race/ethnicity, family income, employment status, marital status, and intention to have a baby.  Results  Descriptive statistics  Table 11 presented the descriptive details of the sample in the current study. Nearly half of the sample was comprised of whites (46%), followed by Black (28%) and Latino respondents (18%). Over half of the sample was married (61%) and approximately equal numbers of respondents were divorced/widowed/separated (20%) or never married (19%). Similarly, over half of the sample was employed full time (54%), followed by the not working (32%). The fewest respondents were employed part time (13%) and the mean age of the sample was over 35. Income was near the higher range, with a mean of over 7, indicating an annual family income of $40,000 or more. A small portion of the sample (16%) reported having intentions to get pregnant. Respondents reported a mean of 8.08 (SD=1.40) for the stigma of infertility scale and a mean of 13.09 (SD=2.10) for the importance of motherhood scale, suggesting that women placed 91  a high importance on motherhood but also believed that a relatively high level of stigma exists within society towards infertile women.   Table 11.  Descriptive Statistics for the Sample for the Importance of Motherhood and the Stigma of Infertility on Confidence in Biomedicine Variable N M  SD Race/ethnicity     White 531 .46 .50 Black 329 .28 .45 Latino 209 .18 .38 Marital status    Married/cohabiting  702 .61 .49 Divorced/widowed/separated 228 .20 .40 Never married  220 .19 .39 Employment status     Employed full time 618 .54 .50 Employed part time 149 .13 .33 Not working 365 .32 .47 Family income 1050 7.60 3.08 Age 1151 35.76 5.87 Intention to have a baby 184 .16 1.52 Independent variables    Stigma of infertility 1126 8.08 1.40 Importance of motherhood 1126 13.09 2.10  In turning to the descriptive statistics by race/ethnic group, results in Table 12 suggested that the majority of white respondents were married (74%), employed full-time (52%), and had an approximate mean age of 36.5. Furthermore, 65% made above $40,000 annual family income and 15% stated a positive intention to have a baby. Whites also had the highest confidence in biomedicine (10.17) compared to Blacks (9.97) and Latinas (9.92).     92  Table 12. Descriptive Statistics for White Respondents Only Variable n M  SD Marital status    Married/cohabiting  530 .74 .44 Divorced/widowed/separated 530 .18 .38 Never married  530 .08 .28 Employment status     Employed full time 531 .52 .50 Employed part time 531 .15 .36 Not working 531 .33 .47 Family income 531 .65 .48 Age 531 36.57 5.79 Intention to have a baby 476 .15 .35 Independent variables    Stigma of infertility 526 8.07 1.31 Importance of motherhood 526 13.55 1.91 Dependent variables    Confidence in biomedicine 526 10.17 1.23   In comparison in Table 13, the majority of Black respondents were never married (40%), were employed full time (64%), and had a mean age of 36. Only 42% of respondents made above $40,000 annual family income, but 19% stated a positive intention to have a baby. Black respondents also indicated a higher level of stigma (8.22) than whites (8.07) and a lower level of importance placed on motherhood (12.61 compared to 13.55) compared to whites. Black respondents also had lower confidence in biomedicine (9.97) than whites (10.17).         93  Table 13. Descriptive Statistics for Black Respondents Only Variable N M  SD Marital status    Married/cohabiting  329 .34 .48 Divorced/widowed/separated 329 .26 .44 Never married  329 .40 .49 Employment status     Employed full time 329 .64 .48 Employed part time 329 .09 .28 Not working 329 .28 .45 Family income 301 .42 .49 Age 329 36.00 5.87 Intention to have a baby 329 .19 .39 Independent variables    Stigma of infertility 321 8.22 1.54 Importance of motherhood 321 12.61 2.29 Dependent variables    Confidence in biomedicine 321 9.97 1.22  Finally in Table 14, the majority of Latina respondents were married (70%), but approximately equal percentages were employed full-time (42%) or not working (43%). The mean age for Latinas in the sample was approximately 34, making them younger on average than whites (mean age of 36.5) or Black respondents (mean age of 36). However, 21% stated a positive intention to have a baby, which was a larger percentage than both Black (19%) and white respondents (15%). In terms of income, 46% of respondents made above $40,000 annual family income, which was higher than the percentage of Blacks (42%) but lower than the percentage of whites (65%). Latinas also stated a lower level of stigma (7.85) than whites (8.07) and Blacks (8.22); and a lower level of importance of motherhood compared to whites (12.67 compared to 13.55) but not Blacks (12.61). Latinas also had the lowest confidence in biomedicine (9.92) compared to whites (10.17) and Blacks (9.97).   94  Table 14. Descriptive Statistics for Latina Respondents Only Variable N M  SD Marital status    Married/cohabiting  209 .70 .46 Divorced/widowed/separated 209 .15 .36 Never married  209 .44 .50 Employment status     Employed full time 209 .42 .49 Employed part time 209 .15 .36 Not working 209 .43 .50 Family income 176 .46 .50 Age 209 33.86 5.65 Intention to have a baby 200 .21 .41 Independent variables    Stigma of infertility 199 7.85 1.40 Importance of motherhood 199 12.67 1.93 Dependent variables    Confidence in biomedicine 199 9.92 1.25   Overall, a larger percentage of white respondents were married and older, on average, compared to Blacks and Latinas. Black women represented the largest percentage of those working full time and the never married. Latinas represented the youngest group, on average, compared to Blacks and whites and were equally represented in the never married and married categories. Latinas also represented the group with the highest percentage of respondents with a positive intention to have a baby compared to Blacks and whites, but the lowest confidence in biomedicine compared to Blacks and whites. Black respondents appeared to experience the highest level of stigma compared to whites and Latinas, but had the lowest importance placed on motherhood and the lowest level of fertility-specific distress. Regression results In turning to the results presented in Table 15, results from Models I and II suggest that both the importance of motherhood and the stigma of infertility were positively and significantly 95  associated with confidence in biomedicine, but the importance of motherhood had a stronger association with confidence in biomedicine. Specifically, in Model I, every one unit increase in the stigma of infertility was associated with a .10 increase in confidence in biomedicine and in Model II, every one unit increase in the stigma of infertility was associated with a .11 increase. In comparison, every one unit increase in the importance of motherhood was associated with a .13 increase in confidence in biomedicine in Model I, and a .12 increase in Model II. That is, both higher stigma of infertility and higher importance of motherhood were associated with higher confidence in biomedicine, but importance of motherhood had a stronger association with confidence in biomedicine compared to the stigma of infertility. Other significant covariates included marital status, whereby being married was associated with a .21 increase in confidence in biomedicine compared to never married status. No other covariates were significantly associated with confidence in biomedicine.  In summary, the importance of motherhood had a stronger association with confidence in biomedicine than the stigma of infertility.                96  Table 15. Regression Models for Stigma of Infertility and the Importance of motherhood on Confidence in Biomedicine   Variable    Model I Model II  Stigma of infertility  .10(.03)***  .11(.03)*** Importance of motherhood  .13(.02)*** .12(.02)*** Intention to have a baby   -.10(.11) Family income  .14(.08) Age   .00(.01) Race/ethnicity    White (reference category)   Black  .02(.09) Latino  -.06(.10) Relationship status   Never married (reference category)   Married/cohabiting  .21(.11)* Widowed/divorced/separated  -.07(.10) Employment status   Unemployed (reference category)    Employed full-time  .04(.08) Employed part-time  -.09(.12) *p<.05; **p<.01; ***p<.001; n=1,151 Discussion and Conclusion My primary aim in this study was to determine if either infertility stigma or the importance of motherhood was associated with confidence in biomedicine to treat infertility. However, before turning to the results of the regression models, I first considered the possible explanations for the descriptive statistics. First, Black respondents cited higher stigma compared to whites in the sample; tBell found that non-therefore Black women are not considered in discussions about infertility. Interestingly, a larger percentage of Black women stated a positive intention to have a baby compared to white women, -white women are subjected to stereotypes that characterize them as overly fertile and outside of the realm of infertility 97  discourse, Black women have intentions to become pregnant even though they are commonly prohibited from entering into discussions about infertility and its solutions. Similarly, Latinas represented the largest group in the sample that stated a positive intention to have a baby. This finding was associated with social stereotypes about non-white women. However, cultural ideals that emphasize family (e.g. familismo) and childbearing within intention to have a baby, since childbearing is considered an important life goal for Latinas, in particular (Becker et al., 2006). Latinas also represented the largest percentage of the not working compared to white and Black women, which may have resulted in motherhood as more of a primary role than other roles, such as participation in the paid labor force. Thus, if motherhood was viewed as a primary role compared to other possible intention to have a baby and bear a biological child to fulfill this goal. Furthermore, white women had the highest importance placed on motherhood compared to Latinas and Black women. In contrast, Black women had the lowest importance placed on motherhood compared to whites and Latinas. The findings for Latinas could be partially explained by prior research that has suggested that Latino/as highly value motherhood (Becker et al., 2006), but it is difficult to know why whites cited a higher importance of motherhood compared to both Latinas and Black women or why Black women cited the lowest importance of motherhood. Perhaps Black women placed a low importance on motherhood because of the stereotypes surrounding Black desires to become mothers.  98  Finally, whites had the highest confidence in biomedicine compared to Latinas and Black women. In contrast, Latinas had the lowest confidence in biomedicine compared to both Black and white women. confidence in biomedicine compared to Black women and Latinas was an expected finding, considering prior research that has found that white women have better access to biomedicine and are more likely to use it than Black women or Latinas (Jain, 2006; White & McQuillan, 2006)confidence in biomedicine compared to white and Black women was also an expected finding, considering prior research that has found that Latinas tend to prefer alternative remedies for their infertility; have a difficult time understanding doctors because of cultural and language barriers; have a difficult time understanding medical conditions, and biomedical treatments for infertility; or may even believe  (Becker et al., 2006; Nachtigall et al., 2009). In turning to the results of the regression models, the results of the analysis supported the notion that both infertility stigma and the individual importance placed on motherhood were associated with confidence in biomedicine to achieve pregnancy. However, personal importance of motherhood had a stronger association with confidence in biomedicine than the stigma of infertility. These findings do not take away from the fact that this analysis found support for the power of stigma in determining fertility-related attitudes, but they do suggest that more research needs to be conducted to fully understand the social level factors influencing fertility-related attitudes such as confidence in biomedicine.  Below, I offered a few preliminary explanations as to why the importance of motherhood had a stronger association with confidence in biomedicine compared to the stigma of infertility. First, if a woman deeply desires to become a mother, she may be more likely to pursue whatever 99  avenues are within her reach and maintain a high confidence in biomedicine to remedy her infertility compared to a woman who feels a great deal of stigma associated with her infertility. To women who place a high value on biological motherhood, medicine represents an agentic possibility in the western world. In contrast, a woman who feels a deep sense of stigma associated with their infertility may view medical interventions for infertility in a different way. It may be that women who feel stigma associated with their infertility do not place as much confidence in biomedicine because it is not as motivating of a factor as placing a high importance on motherhood. Overall, future research would do well to continue an investigation into the possible mechanisms influencing the stigma of infertility and its relation with confidence in biomedicine. In addition, being married was the only covariate that was significantly associated with confidence in biomedicine. This finding was expected, considering married women likely feel a greater pressure to fulfill social norms associated with biological reproduction and would therefore place a higher confidence in biomedicine to remedy their infertility and help them to meet societal expectations of femininity. That is, previous research has found that the ideal family type includes two heterosexual, married parents, with biological offspring (Fisher, 2003; Parry, 2005; Wegar, 2000). Although this category included the cohabiting, the number of cohabiting respondents alone was much smaller in the sample (n=19) than the married (n=683). ariable included in this analysis represented the married more so than the cohabiting. The fact that no other covariates were significantly associated with confidence in biomedicine points to the need for continued research on diverse populations to determine which other factors might be influential in determining attitudes. 100  The main contribution of this analysis was guiding framework to understand fertility stigma and confidence in biomedicine. theory has been applied in the context of infertility, but to date no other research has attempted to interrogate the relation between stigma and confidence in biomedicine. However, there were some limitations to the current analysis. First, the sample was primarily comprised of married women over the age of 35. In addition, most of the women in the sample (regardless of race/ethnicity) were working full-time and had a family income of $40,000 or more per year. The homogeneity of the sample may have impacted the results for confidence in biomedicine, as far as differences that may exist between women of various income levels, employment statuses, and race/ethnic groups. Prior research has also trying/not t-specific distress when they do not become pregnant. Incorporating xperiences (Greil et al., 2011). This analysis was not able to include multiple categories of intention to have a baby because of small cell size for some of the categories. In addition, the data were cross-sectional because this analysis only utilized Wave 1, therefore not allowing for causal linkages between the independent variables and outcome. It is also important to note at this point that because the data were cross-sectional, so that causal linkage could not be established between the independent and dependent variables, it may be that the relationship between the stigma of infertility and confidence in biomedicine could be reversed. In other words, confidence in biomedicine could be associated with a stronger perception of stigma. (i.e., a woman may have higher faith that biomedicine can remedy infertility, and therefore perceives more stigma against 101  infertility under the assumption that an infertile person has the power to end their infertility through the use of biomedicine, but they choose not to do so).  Finally, the measure of stigma I used in this analysis was limited for several reasons. First, the measure of stigma was  of stigma within society (i.e. people who have a hard time getting pregnarather only includes three items to measure the construct. Other research has posited that stigma is best measured using several dimensions. Specifically, Bresnahan and Zhuang (2011) found support for five dimensions of stigma (i.e. labeling, negative attribution, separation, status loss, and controllability) using the maximum likelihood method of factor extraction out of the 105 possible dimensions mentioned in prior research to measure stigma. Because this was a secondary data analysis, the variables utilized in the study did not directly measure the particular research questions presented in this chapter. Despite these limitations, the NSFB remains one of the most useful data sets to study infertility-related phenomena at the structural and individual psychological levels. Future research would do well to continue an investigation of the social-structural and individual psychological factors affecting  to infertility, including their confidence in biomedicine. In addition, it is important to continue research on non-white and low income groups of women, particularly because biomedicine represents an arena imbued with power differentials that typically bar these groups from accessing medical treatment and potentially lowering their faith in such treatments. While treatments for infertility are not a panacea, the structural inequalities that exist within this realm make it impossible for some 102  women to develop a fully informed attitude towards biomedicine, including how it may be useful to remedy their infertility.103  REFERENCES104  REFERENCES  Andersen, A., Wohlfart, J., Christens, P., Olsen, J., & Melbye, M. (2000). Maternal age and fetal loss: population based register linkage study. BMJ, 320, 1708-1712.  Journal of Marriage and Family, 62, 1192-1207. Becker, G. (2000). The Elusive Embryo. University of California Press: Berkeley, CA. Becker, G., Castrillo, M., Jackson, R., & Nachtigall, R. (2006). 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Adoption, family ideology, and social stigma: Bias in community attitudes, adoption research, and practice. Family Relations, 49, 363-369. White, L. & McQuillan, J. (2006). No Longer Intending: The Relationship between Relinquished Fertility Intentions and Distress. Journal of Marriage & Family, 68, 478-490. 107  CONCLUSION My primary aim in this dissertation was to explore the stigma of infertility compared to the individual importance of motherhood and compare how these influenced fertility-related outcomes. These fertility-related outcomes included: 1) fertility-specific distress; 2) fertility-specific distress with social support as a moderator; and 3) confidence in biomedicine. First, Chapter 1 results suggested that the stigma of infertility was positively and significantly associated with fertility-specific distress, while the importance of motherhood was not. In other words, the results of this analysis suggested that the more infertility stigma women perceived, the higher the fertility-specific distress. This finding lent (1963) theory of stigma in the context of infertility. Specifically, the results provided evidence that pronatalism is a powerful social force, and that this ideology likely has influence in prompting women toward biological motherhood. Women may feel pressure to have a child by a certain time in life (e.g., by the end of the childbearing years) in order to avoid appearing deviant to other members of society. That is, although infertility is not a visibly deviant status in terms of its evidence on or in the body, it is a deviant status because of the absence of children at a particular life stage. As previous research has shown (Park, 2002), other members of society are likely to notice if a woman does not have children and she is within the childbearing years, leading them to place her outside of normative social boundaries. Even if a woman experiencing infertility does not face the unwanted questioning from friends, family members, or acquaintances that Park (2002) detailed in her analysis, a woman is nevertheless aware of her own deviation from social norms, leading to higher fertility-specific distress. In turning to Chapter 2, results suggested that social support did not moderate the relationship between the stigma of infertility and fertility-specific distress or the importance of 108  motherhood and fertility specific distress. However, social support on its own was significant, lending weight to prior research findings that social support has the potential to reduce negative outcomes such as fertility-specific distress (Cobb, 1976; Wortman & Conway, 1985). It is still unclear how social support may interact with the stigma of infertility or the individual importance placed on motherhood. It may be beneficial to consider that the type of social may all result in different levels of fertility-specific distress in the context of stigma.  None of the sociodemographic variables in Chapter 1 were significantly associated with fertility-specific distress. This finding does not diminish the fact that age, race/ethnicity, and other factors have been found to have a significant influence on in the context of infertility in other research (e.g., Bell, 2009). Instead, the lack of significant results may point to some limitations of the data set utilized in this analysis, such as homogeneity of the sample. Specifically, the sample was largely comprised of married women over the age of 35, who were employed full-time and had a family income of $40,000 or more per year. Perhaps a more diverse sample in terms of income, age, employment and marital status would result in more significant results for these factors and their relation to fertility-specific distress. However, full-time and part-time employment (compared to not working status) were positively and significantly associated with fertility-specific distress in Chapter 2. I suggested that although employment status may provide an alternative source of fulfillment for women in the face of infertility, occupation is a better predictor of alternative life satisfaction than merely having a job. Additionally, there were some significant findings for covariates in Chapters 1 and 2. For example, intention to have a baby was positively and significantly associated with fertility-109  specific distress in Chapters 1 and 2. These findings support previous research that has suggested that intention to have a baby is positively and significantly associated with fertility-specific distress (Greil et al., 2010; McQuillan et al., 2011). This is an important consideration when focused on the outcome of fertility-specific distress, since the medical definition of infertility is commonly used as the barometer to determine who is infertile. If a woman does not consider herself infertile, however, she is unlikely to heed the medical definition of infertility, and therefore may not experience much distress if she does not conceive within the specified time period of 12 months of unprotected intercourse.  Finally, Chapter 3 results suggested that both the importance of motherhood and the stigma of infertility were significantly and positively associated with confidence in biomedicine. However, personal importance of motherhood had a stronger association with confidence in biomedicine than the stigma of infertility. These findings do not take away from the fact that this analysis found support for the relation between stigma and attitudes about infertility, but do suggest that more research needs to be conducted to fully understand the social level factors influencing fertility-related attitudes such as confidence in biomedicine. Possible explanations for the stronger relation between the importance of motherhood and confidence in biomedicine included the notion that if a woman deeply desires to become a mother, she may be more likely to pursue whatever avenues are within her reach and maintain a high confidence in biomedicine to remedy her infertility, compared to a woman who feels a great deal of stigma associated with her infertility. To women who place a high value on biological motherhood, medicine represents agentic possibility in the western world. In contrast, a woman who feels a deep sense of stigma associated with her infertility may view medical interventions for infertility in a different way. For example, a woman who feels a deep sense of stigma may not place as high of confidence in 110  biomedicine to get pregnant compared to women who place a great deal of importance on becoming a mother. Overall, future research would do well to continue an investigation into the possible mechanisms influencing the stigma of infertility and its relation with confidence in biomedicine.  In Chapter 3, marital status was the only covariate significantly associated with confidence in biomedicine . This finding is expected, considering married women likely feel a greater pressure to fulfill social norms associated with biological reproduction and would therefore place a higher confidence in biomedicine to remedy their infertility and help them to meet societal expectations of femininity. That is, previous research has found that the ideal family type includes two heterosexual, married parents, with biological offspring (Fisher, 2003; Parry, 2005; Wegar, 2000). Although this category included the cohabiting, the number of cohabiting respondents alone was much smaller in the sample the married more so than the cohabiting. The fact that no other covariates were significantly associated with confidence in biomedicine points to the need for continued research on diverse populations to determine which other factors might be influential in determining attitudes. Overall, this dissertation research contributed to the study of infertility from a theoretical, methodological and substantive stance. First, this research contributed to the body of literature on infertility from a sociological perspective, thereby enhancing the existing theoretical knowledge on the topic. A plethora of research has been conducted within the biomedical field, and a burgeoning body of literature also exists within the psychological discipline and offers practitioners methods of helping infertile individuals or couples learn coping techniques to deal with the mental and emotional strain. However, much less research has analyzed infertility from 111  a structural viewpoint, such as the stigma of infertility. Because one of the primary aims of sociological research is to uncover the structural level factors implicit in micro level interactions (e.g., those experienced by infertile women with family, friends, and coworkers), this dissertation research made great strides in accomplishing this goal by taking both the structural and psychological levels into account. This research also extended o the realm of infertility. Specifically, this research provided support for the power of stigma in influencing fertility-related outcomes such as distress.  Second, this dissertation offered a methodological contribution to the existing research on infertility. It is difficult to find a nationally representative dataset that incorporates questions about social processes as well as individual psychological processes, but the NSFB offers variables that measure both. In addition, psychological and attitudinal components and their influence on various outcomes are difficult to measure, but the NSFB offers several scales that measure psychological and attitudinal items with excellent Cronbach. By utilizing the NSFB, this dissertation aided in untangling the complex relationships between the structural and psychological levels, thereby providing a fuller understanding of the infertility experience on women, the associated gender ideologies that may compound the problem, and the attitudes and perceptions that infertile women develop.  Finally, my analysis added to the substantive research on infertility because I considered the structural and psychological facets of infertility that affect women. Specifically, my consideration of the stigma associated with infertility, as well as the psychological importance that women may place on becoming mothers, may help mental health professionals to better address the negative psychological outcomes associated with infertility at multiple levels. In addition, when armed with both the structural and psychological influences associated with 112  infertility, doctors them towards the proper coping resources as they navigate the infertility experience within the clinical setting. Finally, by drawing attention to the stigmatized nature of infertility within society, we may be able to move beyond these deviant characterizations of those struggling with the problem and increase societal awareness and empathy. Doing so could reduce negative outcomes such as distress for those facing infertility. Despite the contributions of my research, it did have some limitations. For example, the data were cross-sectional because this analysis utilized Wave 1 of the NSFB only, thereby limiting understanding of the causal nature of relationships between the independent and dependent variables. Furthermore, because this was a secondary data analysis, the variables utilized in the study did not directly measure the particular research questions presented in each chapter.  In Chapters 1 and 2, the fact that the sample largely cited a low level of fertility-specific distress may have affected the results. Prior research has also warned that dichotomizing ons into trying/not trying may be problematic, as this analysis did, -specific distress when they do not become pregnant. Incorporating multiple categories of intentions may help to more accurately However, I was not able to include multiple categories of intention to have a baby because of small cell size for some of the categories. Finally, the measure of stigma I used in this analysis was limited for two reasons. First, the people  personal experiences of stigma because it only included three items to measure the113  construct. Second, the measure of stigma in the NSFB only included three items to measure the construct. Other research has posited that stigma is best measured using multiple dimensions. Specifically, Bresnahan and Zhuang (2011) found support for five dimensions of stigma (i.e. labeling, negative attribution, separation, status loss, and controllability) using the maximum likelihood method of factor extraction out of the 105 possible dimensions mentioned in prior research to measure stigma. In general, future research should aim to incorporate the experiences of non-white  and strive towards incorporating non-clinical samples of women facing infertility. Future research would also benefit from further interrogation of the stigma of infertility and the importance of motherhood and their relation to various fertility-related outcomes. Although it is difficult to disentangle the individual and structural levels, it is nevertheless an important task that may help mental health or medical professionals to understand and alleviate negative infertility outcomes such as distress. Overall, more data collected on the specific experiences of individuals and social stigma due to their infertility would greatly help to elucidate this powerful social force. 114   REFERENCES  115  REFERENCES  -infertility. Gender & Society, 23, 688-709. Bresnahan, M., & Zhuang, J. (2011). Exploration and validation of the dimensions of stigma. Journal of Health Psychology, 18, 421-429. Cobb, S. (1976). 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