Changing the perspective on low birth rates: why simplistic solutions won’t work

BMJ 2022; 379 doi: https://doi.org/10.1136/bmj-2022-072670 (Published 15 November 2022)Cite this as: BMJ 2022;379:e072670

Stuart Gietel-Basten, Anna Rotkirch, and Tomáš Sobotka argue that policies responding to population decline and ageing should enable reproductive choice and maximise the potential of all citizens

The news that birth rates hit record low levels in many countries in Europe, Asia, and the Americas in the past decade was met with some alarm globally. More than half of the world’s population lives in countries with a total fertility rate below two children per woman. The rate is below 1.5 in 46 countries, and ranges from 1.3 to 1.8 in many middle income countries such as Brazil, Iran, China, Turkey, and India. Countries that, until recently, had fertility rates around 1.8-2.0 such as France, US, UK, and those in the Nordic region also now have declining birth rates. In South Korea the rate fell to 0.81 children per woman in 2021, an unprecedented low for any country in peacetime. Adversities and anxieties linked to the covid-19 pandemic, Russia’s invasion of Ukraine, and climate change may further contribute to fertility declines.

Countries with a total fertility rate below 2 in 2020

As a primary engine of population ageing and stagnation, low birth rates are often viewed as a threat to welfare systems, healthcare, and the economy. The concern is that lower birth rates imply that, in several decades, there will be fewer economically active people to fund health and welfare systems as well as increasing demands on these systems. Rather than reforming such stressed systems through, for example, altering the pension age or raising tax (which may be politically unpopular), many governments have sought to find a demographic solution by pursuing top-down, target driven policies to encourage childbearing. Such policy responses have questionable justifications, limited effect on fertility, and potentially harmful effects on sexual and reproductive health, human rights, and gender equality.

People in countries with low fertility rates desire, on average, to have more children than they do. Adopting a person centred, inclusive, rights based, and gender sensitive approach to fertility, following principles set out at the 1994 International Conference of Population and Development (ICPD), is more likely to deliver a sustainable response to low fertility.

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