Decreasing Fertility Rate in the United States: Demographics, Challenges, and Consequences

Overall birth and fertility rates in the United States (U.S.) have declined since 1960,¹ a demographic trend shared by many other countries, and one with significant ramifications.² These statistics are not demographically uniform in the U.S. and, indeed, conceal a decreasing but still high teen birth rate in the U.S.³ This Perspective broadly discusses the implications of these reproductive trends in the U.S.

Decreasing Fertility Rate in the US

The number of births in the U.S. in 2021 decreased 14% since 1960.¹ Between 1960–2002, the general fertility rate decreased 45%,¹ with an average 1% decline in births between 2014–2019, and 2% decline between 2007–2013 (Figure 1).⁴

Figure 1.

As of 2021, the total U.S. fertility rate is 1.664 children/woman which is below a population replacement fertility level of 2.1 children/woman;⁴ age-specific birth rates and mean age of mothers have both increased. In 2021, women aged 30–34 had higher birth rates than those aged 25–29, with 97.6 births/1000 women and 93.0 births/1000 women, respectively; these rates far exceed those for women aged 20–24 years.⁴ In 2021, the overall mean age of mothers at first birth was 27.3 years⁴ compared with 24.9 years in 1968.¹ This trend is uniformly observed for Black, White, and Hispanic women.^1,4

U.S. Teen Birth Rate – Highest in the Developed World

While the U.S. overall fertility rate is falling, its teen birth rate is the highest among industrialized nations.³ For example, compared with Canadian, Swedish, and Swiss teens, U.S. teens are far more likely to give birth (Figure 2),⁵ despite the 76% decline in American teen births from 1991 to 2022.^3,5

Figure 2.

The National Surveys of Family Growth (NSFG) and Youth Risky Behavior Surveillance (YRBS) data afford insights regarding such teen birth rates. The NSFG collected data between 1982–2008 on ~10,000 women of childbearing age regarding sexual activity, contraceptive use, and pregnancies. The YRBS system collects biannual sexual activity and contraceptive use data on teenagers.³ These surveys reveal the following: socioeconomic marginalization leads many teenage girls to have children while young and unmarried;³ teens in the highest socioeconomic-inequality states in the US are more likely to give birth than teens in the lowest inequality states;³ teen births are more likely in those in poverty or single-parent households;³ and teen births are more likely in daughters of women who are high school drop-outs compared with daughters of women with some college attendance.³

The roles of sexual activity and contraceptive use among U.S. teenagers are also relevant. While reported sexual activity may be lower in U.S. teens compared with British teens, the YRBS survey revealed consistently lower contraceptive use among U.S. teens compared with teens from other developed nations,^3,7,8 and that US teens are more likely not to use any form of contraception.⁶ American teens, especially those who are younger and from low-income backgrounds, are more likely to choose condoms rather than more effective contraceptive methods.^7,9.

Implications of Decreasing Fertility Rate in the U.S

Older women primarily account for the U.S. fertility rate. The deferment of marriage and child-bearing has resulted in unprecedented numbers of couples desiring pregnancy relatively late in life, with the associated decline in fecundity and increase in infertility.¹⁰

Female fertility decreases with age. For example, 1/7 couples are infertile at 30–34 years, and 1/4 at 40–44 years.¹⁰ Additionally, fertility may also decrease with advancing male age.¹¹

The National Assisted Reproductive Technology Surveillance System (NASS) and the CDC’s VitalStats databases show that the number of annual ART (Assisted Reproductive Technology) cycle starts in the U.S. grew steadily at ~5%/year between 1997 to 2013; ART usage more than doubled between 2012 to 2021.¹³ However, analysis of supply-versus-demand data for ART services reveals that only 24% of the U.S. need for ART services is currently being met.¹⁴ Based on the European Society of Human Reproduction and Embryology’s (ESHRE) estimated ART “demand” figure of ≥ 1500 cycles/10⁶ population/year, the U.K., Scandinavia, and Australia have satisfied 62%, ≥ 100%, and ≥ 100% of their national ART needs, respectively.¹² Compared to other members of the Organization for Economic Co-operation and Development (OECD), the U.S. clearly lags.¹²

The 2009 WHO designation of infertility as a “disease” aimed to dispel the proposition that infertility care is elective.^12,15 Infertility services may thus be viewed as a protectable right under the Convention on the Rights of Persons with Disability.¹² However, within the U.S., Supreme Court rulings have affirmed the states’ responsibility to protect individual rights, but not necessarily to provide for them.¹² The right to procreate is therefore severed from state-sponsored underwriting of general infertility and ART services.¹²

Since Maryland’s 1984 introduction of infertility coverage, 22 states including Washington, D.C. currently have infertility mandates.¹⁶ However, limitations for infertility treatment exist within these mandates. For all 23 mandates, employers self-insuring are exempt, and some mandates require insurers to offer coverage, but allow employers to select policies excluding fertility coverage.¹⁵ Other limitations include lifetime maximum dollar amounts for infertility services and the number of IVF cycles.¹⁵ Infertility care for single, transgender, or women and men in same-sex relationships often limits access,¹⁵ while the inclusion definition of infertility often requires couples having had at least “12 months of unprotected intercourse without conception”.¹⁵ Restrictive criteria can include policy-specific treatment algorithms proscribing specific treatments (e.g., intrauterine insemination before IVF); exclusion based on biologic tests (e.g., arbitrary levels of ovarian reserve markers); mandates precluding coverage of donor gametes; and mandates offering limited coverage for evaluation and treatment of male partners.¹⁵

Additionally, there is a regional disparity of ART centers in relation to residential locations of populations in their reproductive years.¹⁷ While there were 453 CDC-reporting ART centers in 2021, the Society of Assisted Reproductive Technology (SART) underscores geographic disparities in care. The most underserved states (≤ 25% of the state’s study population within 60 minutes of any ART center) include: Alaska, Montana, Wyoming, and West Virginia.¹⁷ Comparatively, the most overserved states (≥ 95% of the total study group within 60 minutes of any ART center) include: Connecticut, Massachusetts, New Jersey, Rhode Island, and District of Columbia (DC); all, except DC, are mandated states.¹⁷ ART services are thus concentrated in the Northeastern U.S., likely reflecting the high number of mandated states and metropolitan areas.¹⁷

Solutions

Society is dependent on population growth for overall economic and societal success.^18,19 Slowly growing populations have higher elderly dependency ratios, that is, the ratio of people aged 65+ to those aged 15-to-64. Conversely, the potential support ratio – the number of working-age people (ages 15–64) per elderly person (ages 65+) - falls as a population ages; fewer workers thus support the elderly.¹⁸ Beyond immigration policies, the solution for this problem is to increase the birth rate, which requires socioeconomic support for reproductive health.

Increased coverage and utilization of fertility services address this population growth problem.¹² Limited access to ART due to restrictive underwriting imposes high rates of underinsurance, uninsurance, and out-of-pocket costs, making the right to build a family dependent on financial resources; indeed infertility services are the highest among women with higher household income.¹²

Reducing financial, infrastructural, and geographic barriers to ART services by increasing ART clinic availability would address these needs,¹² and increase U.S. fertility and population growth rates. Financial support for fertility services improves both birth rates and the safety and success of such treatments. Funding for fertility care significantly decreases multiple pregnancy rate;^15,19 as multiple pregnancies have higher risk of complications and hospital stays, this lowers the total costs of both antenatal and neonatal intensive care.¹⁹ In the U.S., each cycle of IVF costs between $15,000 and $20,000.¹³ As most women require on average 2.5 cycles to conceive, successful conception may exceed $40,000.¹³ With 2022 median U.S. household incomes at $74,580,²⁰ such costs may be prohibitive.

Teen pregnancy also reflects the overarching problem of limited access to reproductive health care. Improving access to effective contraception relies on reproductive health education. A 2018 survey of the WHO European Region showed that there were legal frameworks for comprehensive sexual education in school within 21/25 countries.²¹ This was closely associated with low teenage birth rates and high levels of oral contraceptive use in these countries.²¹ The concern that sexual education can “spoil children’s innocence” often promotes opposition to such education, and the persistence of “abstinence-only” programs, despite clear evidence of the failure of such programs.²¹ Avoidance of teen birth improves not only the socioeconomic outlook for those involved, as children of teenage mothers fare worse – cognitively, economically, societally - than other children.

Conclusion:

Given the long-term national impact of both teen pregnancy and decreased fertility rate, there should be focused attempts to improve both reproductive health education and therapeutic and other strategies that counter the declining fertility rate.