Why are American women ‘underbabied’?

The views expressed by contributors are their own and not the view of The Hill

Last month, Dr Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services, called American women “underbabied” in response to new data that showed the U.S. at its lowest fertility rate ever: just under 1.6 births per woman, below population-replacement levels.

He joined a storm of politically diverse pundits who have offered their own explanations for women’s reluctance to have more children. These include women’s education and employment and consequent “woke” values; the widespread availability of contraception and abortion; exaggerated faith in egg freezing and IVF as solutions; fertility-damaging environmental exposures and poor health; anxiety about the climate, economic, political, and social unraveling; and even social isolation fueled by smartphones.

Low birth rates are indeed worrisome. They foretell labor and care shortages, and reveal a society without hope for the future. While the factors listed may contribute to the decline in birthrates, there are also glaringly obvious structural reasons that are unique to the U.S. If we want to make a dent in the problem, it is imperative that we reframe our policy analysis to focus on these core drivers.

To start, Americans live in the only highly developed country that does not guarantee even minimal paid leave for employed new parents or to take care of an ill child. Although 13 states plus the District of Columbia have passed bills to mandate paid family and medical leave insurance programs, most have not done so, leaving about 73 million workers without such a resource. However, even in states that mandate paid leave, the benefits offered are far lower than salaries, so that many cannot afford to take the leave.

Moreover, many of those who work during pregnancy face discrimination and working conditions that imperil their health. Although President Biden signed a bill in 2022 that requires employers to accommodate pregnant workers, the recently appointed chair of the federal agency responsible for implementing these regulations, the Equal Employment Opportunity Commission, has reduced employer reporting requirements and cut the commission’s own workforce by 25 percent.

Americans may also be deciding not to have children because childcare is often not available: 36 states suffer from a childcare availability gap greater than 20 percent between open slots and the number of children requiring care. An estimated 46 percent of America’s children under age six live in a licensed child care desert.

At the same time, childcare is unaffordable in every state. Even with both parents working — which is the case for more than two-thirds of the nation’s children — child care costs can consume huge portions of household income.

Women are also already paid less than a man doing the same job, and having children only widens that gap. As recent research has shown, working women on average see their incomes cut in half after having children, and their earnings remain depressed for years.

At the same time, if women are unemployed or have wages low enough to qualify for Medicaid, they now must also be employed to obtain this coverage, thanks to last year’s One Big Beautiful Bill Act. When receipt of welfare benefits was conditioned on work requirements several decades ago, my research team documented that mothers of sick children could not simultaneously care for their child and comply with the work requirements. They either lost their jobs or their children became sicker.

Then there are the severe abortion restrictions implemented over the last several years, which mean that if a woman were to become seriously ill during pregnancy, the state will let her die rather than provide medical care. Women in Georgia, Texas and North Carolina have died when their life-threatening infections, irregular heart rates and bleeding did not receive appropriate care because treatment required ending the pregnancy. Recent studies estimate that maternal deaths have increased by as much as 8 percent in those states with severe restrictions on abortion.

And if the fetus were to be diagnosed with a life-threatening birth defect, women in these states will be forced to carry it until delivery and then watch it suffer or die. Infant deaths in Texas increased by 11 percent after Texas pioneered such restrictions, mostly attributed to lethal birth defects in pregnancies that had not been terminated.

Taken together, these conditions don’t make motherhood enticing — or even feasible.

The U.S. is actually several decades late to the global conversation about declining birthrates as our birthrates had hovered above replacement level thanks to immigration, until recently.

Various governments across the world have tried specific policies to remedy the birth dearth but found that tackling only one issue of this multifaceted trend failed to increase births. While we need to better understand the contributions of social and economic anxieties on fertility rates, we could start by comprehensively tackling the many concrete obstacles that make it so difficult to be parents in the U.S.

Wendy Chavkin, MD, MPH, is professor emerita of Public Health and Obstetrics-Gynecology at Columbia University. She began research on policy responses to declining birthrates 20 years ago and is the author of the 2010 book “The Globalization of Motherhood” (Routledge Press).