Intended for healthcare professionals

CCBYNC Open access

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

BMJ 2022; 379 doi: (Published 15 November 2022) Cite this as: BMJ 2022;379:e072670
  1. Stuart Gietel-Basten, professor12,
  2. Anna Rotkirch, research professor3,
  3. Tomáš Sobotka, senior researcher4
  1. 1Hong Kong University of Science and Technology, Kowloon, Hong Kong SAR, People’s Republic of China
  2. 2Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
  3. 3Population Research Institute, Väestöliitto, Family Federation of Finland, Helsinki, Finland
  4. 4Vienna Institute of Demography, Wittgenstein Centre for Demography and Global Human Capital (IIASA, OeAW, University of Vienna), Vienna, Austria
  1. Correspondence to: S Gietel-Basten stuart.gietelbasten{at}

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 (fig 1), and ranges from 1.3 to 1.8 in many middle income countries such as Brazil, Iran, China, Turkey, and India.1 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.2

Fig 1
Fig 1

Countries with a total fertility rate below 2 in 20201

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.3 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; box 1),6 is more likely to deliver a sustainable response to low fertility.

Box 1

1994 UN International Conference of Population and Development

Big changes in health and longevity drove an increase in global population from 2.5 billion in 1950 to 5.3 billion by 1990.1 This perceived unrestrained demographic growth resulted in fears of resource scarcity, environmental collapse, and overcrowding,4 leading stakeholders to advocate reducing fertility, sometimes through coercive and draconian measures such as China’s one child policy.5

The 1994 International Conference of Population and Development (ICPD) affirmed that sustainable demographic change was key to shaping macroeconomic prospects.6 However, its programme of action marked a paradigm shift by focusing on reproductive health, gender equality, and individual wellbeing rather than governmental needs or demographic targets.7

Implementation of the ICPD programme has not been without controversy. The voluntary family planning it espoused has been linked to an overarching narrative of fertility reduction and presented as way to resolve development problems.8 There was also much disagreement concerning funding, integration, and the right to induced abortion and its role in reproductive health services.91011

Still, the core principles remain valid: individuals should be empowered to realise their reproductive goals on the basis of human rights, dignity, and gender equity within the context of sexual and reproductive health and rights.12


Target driven pronatalism risks health

Almost all countries with a total fertility rate below 1.5 have policies in place to raise fertility (fig 2).13 Many governments have launched policies intended as a quick, politically expedient demographic fix to the challenges of population ageing and stagnation.14 Rather than follow ICPD principles, countries such as Belarus, Japan, Republic of Korea, Hungary, Turkey, Poland, and Russia have adopted pronatalist policies that use narrowly oriented interventions to encourage or pressure women to have more children to reach a target fertility rate (usually around two children) and population size.15 Although financial support for new parents is common in welfare systems around the world,16 in target driven pronatalism payments are intended to encourage marriage and larger families. Some examples include the “baby bonuses” in Singapore, which pay out more for couples with three or more children; interest-free loans to prospective parents in Hungary that do not have to be repaid if a couple has at least three children within five years; and the “maternity capital” in Russia, a one-off benefit that has been provided to mothers of second or third children since 2007.17

Fig 2
Fig 2

Countries with a stated policy aim to raise fertility, 201513

Of equal importance to the actual policies is the rhetoric surrounding them, which often combines the “mission” to raise birth rates with a promotion of conservative family values, where women have a duty and responsibility to bear children and thus secure the future of the nation.16 By promoting the childrearing role of mothers while ignoring men’s contribution, top-down pronatalist policies and discourses tend to reimpose conservative family and gender roles and reverse progress on gender equity and rights for sexual and gender minorities.1819 Access to abortion, contraception, and sexual education is often curbed. In Poland, for example, restrictions on abortion were further tightened in January 2021, shortly before the government presented its demographic strategy, which aims to “get out of the trap of low fertility rate.”20 In Iran, as a part of the push to increase fertility, a law enacted in November 2021 curbs access to abortion, eliminates free provision of contraception, prohibits voluntary sterilisation, restricts prenatal screening, and broadens surveillance on access to family planning services.21 In China, the latest round of policies designed to achieve “an appropriate childbearing level” includes provisions to “reduce abortions that are not medically necessary.”22 Certain groups (eg, unmarried parents, sexual and gender minorities, and couples without children) can be stigmatised and penalised.

Target driven policies are often embedded within an authoritarian and ethnonationalist propagandist discourse. The “general population policies” announced by the supreme leader of Iran, Ayatollah Khamenei, in 2014 called for “promoting and establishing an Islamic-Iranian lifestyle and confronting the negative aspects of the western lifestyle.”23 In Turkey, President Erdoğan has declared that all families should have at least three children.24 Russia’s president Vladimir Putin reintroduced the Soviet era medal for “mother heroines” with 10 or more children in 2022,25 and deputies of the Russian State Duma introduced a bill banning information promoting the “foreign child-free ideology.”26

Ethnonationalism becomes explicit in discussions of differential fertility rates by ethnic groups, as exemplified in the discourses about perceived high fertility among the Roma ethnic group in central and eastern Europe, including Bulgaria.27 Although immigration can slow the pace of population ageing and counter fertility decline, it contradicts ethnonationalist goals. Hungary’s prime minister, Viktor Orbán, has emphasised that government population policies aimed at increasing the number of Hungarian children are a fight against “a suicidal attempt to replace the lack of European, Christian children with adults from other civilisations—migrants.”28

Miscalculated approach

Target based pronatalist policies often rest on a questionable assessment of demographic measures and change and are thus unlikely to achieve their objectives. Firstly, pronatalist policies often affect the timing and spacing of births rather than the total number born to a particular cohort of women—for example, the short lived baby booms in Russia in the 1980s and 2000s following more generous family benefits.29 Restrictions to abortion have historically led to a rise in illegal abortions and worse health for women and children, without long term fertility gains.30 Secondly, population decline in many low fertility settings, especially in central, southeastern, and eastern Europe, has been exacerbated by emigration brought about through poor employment opportunities.31 Simply put, if babies that are born because of pronatalist policy move away to work elsewhere at the earliest opportunity, the net population impact is zero.

Reproductive empowerment

The international and moral consensus against target driven birth policies was settled at the ICPD (box 1).6 It affirmed a health and human rights approach that prioritises empowering individuals to realise their reproductive goals as the mechanism by which to influence fertility rates. The ICPD principles, which aim to reduce the gap between desired and actual fertility, were successful in lowering high birth rates and can now also help governments to avoid very low birth rates. This consensus has been restated in various follow-on summits, such as ICPD+25 Nairobi 2019, and with target 3.7 of the sustainable development goals calling for universal access to sexual and reproductive healthcare services, and the integration of reproductive health into national strategies and programmes.

In countries with low fertility rates, many people aspire to have more children than they end up with.3 The gap between fertility aspirations and actual family size—combined, in some countries, with high rates of emigration—are often symptoms of societal and economic dysfunction, including discrimination, imbalanced labour market, gender inequality, an unsustainably work oriented culture, and inadequate social support for families and young adults.19 Countries with low fertility rates need comprehensive policies to support the healthy growth and development of families.32 These include, for example, high quality and affordable childcare provision, flexible and well paid parental leave, work flexibility, job protection for parents, and policies supporting both partners’ involvement in child rearing.

Some middle and higher income countries, including Estonia, Moldova, and Uruguay, have recently adopted such inclusive family policies while also broadening access to health and social policies.3334 Financial transfers provided in many higher income countries (such as monthly child allowances, paid maternity and parental leave schemes, subsidised early childhood education, and dedicated marriage or housing loans) also offset some direct costs of childbearing and reduce poverty among families with children.35

Gender sensitive family policies can offset some of the indirect costs of family formation, which are disproportionately shouldered by women, while also addressing men’s wishes and challenges related to childbearing. Currently, access to sexual and reproductive health services is highly unequal both between and within countries.3637 Single women and gender and sexual minorities are often unable to access fertility treatment.3839 Demand for assisted reproductive technology and (in)fertility counselling is growing—not least because of rising parental ages and involuntary childlessness.4041

Historically, generous family policies in France, Germany, and Estonia, for instance, have been partly linked with stated pronatalist goals. However, family friendly policies in these countries today are aligned with human and reproductive rights and support families to maximise social and economic wellbeing rather than arbitrary goals of the state. Hence, governments concerned about demographic trends should give more priority to initiatives to prevent infertility and involuntary childlessness and raise fertility awareness and reproductive empowerment. Young adults should be provided with the skills and services needed for planning their family life, just as they plan their work careers. Such educational and medical services need to be sensitive to the needs and wishes of different families, without stigmatising child-free lifestyles. These policies should be built on a strong grounding of sexual and reproductive health and rights and enhance family and children’s wellbeing.

Beyond birth rates

Even if slightly higher birth rates can be achieved, major societal changes need to be tackled now, irrespective of future birth trends. Urgent reform of health and welfare systems is required to meet the demands of an ageing population.42 Other dimensions of population change, especially education and health, contribute to increased wellbeing and productivity and could offset many of the challenges linked with population ageing.43

Countries with smaller, older populations need to realise the full social and economic potential of all citizens, including migrants and their families. This involves continued investment in maintaining wellbeing and good health from infancy into old age, which is lagging in many countries, including the UK.44 Countries with recent target driven policies such as Iran and Turkey often have much potential to maximise their existing human capital, not least through lowering child poverty and youth unemployment and increasing female participation in the labour force.45

Focusing on the wellbeing of children and their families and caregivers should be the first priority of every ageing society. Countries in the early stages of population ageing can also learn lessons from demographically older countries and create sustainable institutions that are resilient to continued demographic changes. This requires working with civil society, the private sector, and families to adopt holistic policies for healthy and active ageing, labour market and pension reform, family friendliness, and better immigration as well as promoting reproductive rights and empowerment. Securing political support to bring about such reforms is not easy, as shown by the slow progress since the ICPD programme of action. However, we must learn from history and push back against attempts to fix the problem by telling women how many babies they should have.

Key messages

  • Low birth rates, linked to population ageing and stagnation, are a source of concern in many countries of the world

  • Many governments have introduced target driven policies to spur the birth rate

  • These policies often negatively affect gender equity, reproductive health, and sexual rights and are unlikely to be successful in their stated aims

  • Other governments have focused on family friendly policies and increasing the wellbeing of all children

  • Governments, civil society, and other stakeholders should concentrate on tackling the key institutional challenges associated with population ageing, enabling all citizens to reach their full potential, and supporting reproductive empowerment


  • Contributors and sources: SG-B, TS, and AR are social science researchers who explore family changes around the world through a multidisciplinary, comparative demographic lens. All three authors have worked extensively on applied family policy, working with governments, civil society, and other stakeholders. All contributed equally to the conceptualisation, development, and writing of the article.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • Publisher’s note: Published maps are provided without any warranty of any kind, either express or implied. BMJ remains neutral with regard to jurisdictional claims in published maps.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: