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There is a concern about declining birth ratesin both the developing and developed world(www.rand.org). Fertility rates tend to be higher inpoorly resourced countries but due to high maternaland perinatal mortality, there is a reduction in birthrates. In developing countries children are needed asa labour force and to provide care for their parentsin old age. In these countries, fertility rates are higherdue to the lack of access to contraceptives and gen-erally lower levels of female education. The socialstructure, religious beliefs, economic prosperity andurbanisation within each country are likely to affectbirth rates as well as abortion rates, Developed coun-tries tend to have a lower fertility rate due to lifestylechoices associated with economic affluence wheremortality rates are low, birth control is easily acces-sible and children often can become an economicdrain caused by housing, education cost and othercost involved in bringing up children. Higher educa-tion and professional careers often mean that womenhave children late in life. This can result in a demo-graphic economic paradox.

The Total Fertility Rate (TFR) of a population isthe average number of children that would be bornto a woman over her lifetime if she were to experi-ence the exact current age specific fertility ratesthrough her life time and she were to survive frombirth through the end of her reproductive life. It isobtained by summing the single year age specificrates for a given time point. Perhaps more relevantto the current debate is the replacement fertility ratewhich is the total fertility rate in which womenwould have only enough children to replace them-selves and their partners. Effectively it is the totalfertility rate at which newborn girls would have anaverage of exactly 1 daughter over their lifetimes. Bydefinition replacement is only considered to have

occurred when the offspring reach 15 years of age.The replacement fertility rate is roughly 2.1 livebirths per woman for most industrialised countries.Due to increased mortality rates, the approximateaverage for developing regions of the world is 2.3.At this rate, population growth through reproductionwill be approximately 0, but still be affected bymale-female ratios and mortality rates

The fertility of the population of the United Statesis below replacement among those native born, andabove replacement among immigrant families andthe socially deprived (Singh et al., 2001). Howeverthe fertility rates of immigrants to the US have beenfound to decrease sharply in the second generationas a result of improving education and income. Itwill take several generations for a real change in totalfertility rates to be reflected in birth rates becausethe age distribution must reach equilibrium. For example, a population that has recently droppedbelow replacement fertility rate continues to growbecause the recent high fertility produced large number of young couples who would now be in theirchild bearing years. The phenomenon carries forward for several generations and is called popu-lation momentum or population lag effect. The timelag effect is of great importance to human populationgrowth rates. The state policy institutes and interna-tional population studies are closely monitoring howreproductive patterns cause immigrant generationsglobally.

Although recent data show that birth rates in theUK have increased (Office of National Statistics,2009), this is predominantly due to immigrationso there are still serious concerns about long termreplacement . There are two potential means of addressing the problem of providing a youngproductive workforce able to generate income to

Declining birth rate in Developed Countries:A radical policy re-think is required

Geeta NARGUND

President, International Society for Mild Approaches in Assisted Reproduction (ISMAAR: www.ismaar.org)Chief Executive, Health Education Research Trust (www.hertrust.org)Medical Director, The Centre for Reproduction and Advanced Technology, London (www.createhealth.org)

Correspondance at: geetanargund@gmail.com

F, V & V IN OBGYN, 2009, 1 (3): 191-193 Opinion paper

192 F, V & V IN OBGYN

provide the social care for the old and infirm. Thefirst is to find ways of increasing the birth rate; thisis essentially a long term solution but one whichshould provide more steady and predictable results.The second is to encourage immigration of a pre-dominantly young and skilled workforce; this mayprovide an instant answer to the problem but is likelyto be short-term unless the immigrants decide to stayin large numbers. In the long term it is doubtfulwhether reliance should be placed on immigrationto solve an intrinsic societal problem in developednations, namely a falling birth rate.

The declining birth rate is not unique toBritain and Western European countries. Countrieslike Japan have a similar concern.

There are several factors such as lifestyle factors,an increase in sexually transmitted diseases, rise inobesity and environmental factors involved in urban-isation and urban lifestyle that are affecting fertilityand have led to rise in male and female subfertility.In addition there are socio-economic factors thathave led to women and couples delaying having chil-dren. Lack of affordable housing, flexible and part-time career posts for women and affordable andpublicly funded (free) child care have contributed tothe current low fertility/birth rates. Couples/womenare delaying starting a family which has led to a truedecline in their fertility levels due to ovarian ageingand related reasons leading to reduced chance ofconception.

It is necessary for governments to provide ade-quate publicly funded reproductive health and socialcare in order to achieve required birth rates and havea younger population to contribute to nation’s andglobal progress. It can be argued that women nowcontribute more to the total workforce and socialwelfare agenda (tax and national insurance) thanever before and deserve to get reproductive benefitsfrom the public purse.

In parallel, it is also necessary to have a nationaland an international initiative for the prevention ofinfertility and protection of fertility. The projects willneed to be focussed at the specific needs of the localpopulation. It is necessary for governments to workin close partnership with the voluntary sector toachieve the maximum effect.

The most important project will have to addressraising awareness at an individual, family, commu-nity and social level as well as at primary, secondaryand tertiary healthcare level regarding factors affect-ing male and female fertility. A regular and openeducation programme for women and men wouldempower them with knowledge required to protecttheir fertility. Furthermore, recent surveys suggestthat prevention of reproductive and sexual healthproblems would be best achieved through education

in secondary schools. It is important to plan apractical and a meaningful initial and follow-upprogramme for reproductive and sexual health edu-cation in secondary schools, with an aim to preventfuture infertility. In developing countries it wouldbe necessary to provide this education to womenand men at grass roots level in their homes andcommunities . This is aimed at increasing naturalconception rates.

Fertility treatment in the UK as in other Europeancountries is currently funded and managed by theDepartment of Health within the government. Sincehealthcare has several priorities such as cancer, careof elderly and acute medicine, fertility care is nothigh on the agenda. This has led to inadequate fund-ing and concerns about inequity. The need for privateassisted conception due to lack of public fundingmay eventually lead to only the rich benefiting fromfertility treatment. This will lead to long term socialinequality. The state should fund the mild IVF treatments which are safer, less costly and have com-parable success rates to the standard downregulationprotocols (Heijnen et al., 2007; Nargund andFrydman , 2007; Verberg et al., 2009; Nargund2009). This will improve access to fertility treatmentfor the socially deprived. The European HumanRights Act (October 2001) recognises “right to family life” as a basic human right. It is also widelyaccepted that “human reproduction” is an importantand fundamental wheel of life with spokes spreadacross societal, economic, population, immigration,employment, education, health, wealth and familylife (Figure 1). It involves sustaining the current family structure for the creation of future genera-tions.

The term “Strategy for Reproduction and Familylife” should replace “Fertility Treatment” in govern-ment policies and should be seen within a wider context as indicated in Figure 1. It should thereforebe funded not just by the Department of Health, butby a dedicated department within the governmentwhich addresses this subject in the short and the longterm in the best interests of the families, societiesand nations. Reproduction is important in order toachieve a balance of family life, diversity, socio-economic equality and progress across communities.It is the only area that spreads not only through across-section of society but also longitudinallythrough generations.

There is a need for collaboration between individ-ual governments, the EEC, United Nations and theWorld Health Organization, to take this strategy forward.

In summary, in order to address declining birthrates:

DECLINING BIRTH RATE IN DEVELOPED COUNTRIES – NARGUND 193

1. There is an urgent need to initiate strategies atlocal/national and international level to preventinfertility and protect human fertility.

2. Early and cost-effective assessment of fertilityproblems and assisted reproduction should beprovided as part of public health care. For exam-ple: a) There should be a strong emphasis on pro-tection of reproductive health in the secondaryschool curriculum. b) Specially designed “pre-conception care” clinics must be establishedwithin the Public Health Service to educate menand women on factors affecting their fertility andto help them help themselves to natural concep-tion. c) An ongoing fertility awareness pro-gramme should be set up for communities fundedby local governments in conjunction with thelocal voluntary sector. A tailored and sensitiveprogramme could enhance the effect in a multi-cultural population. d) A long-term plan foraffordable housing for young couples shouldcontinue . This could help couples plan an earlyparenthood. e) Provision of affordable and highquality child care facilities should be available.f) Flexible, part-time career posts for womenshould be a priority.

3. The government should prioritise the provisionof safe, mild and cost-effective assisted reproduc-tion treatments (ART) with single embryo transfer (SET) so that more treatment cyclescould be offered within the available healthbudget. This would save costs associated with

drugs, hospital admissions for OHSS and multiple pregnancies.

4. The role of immigration trends in improving birthrates and its long-term effect need to be evalu-ated.

5. “Strategy for Reproduction and Family life”should replace “Fertility treatment” as a govern-ment policy and it should be dealt with acrossmany departments as indicated in Figure 1 toboost the birth rate and national economy,employment , family life and societal growth. A separate department must be established topromote family life.

References

Heijnen EM, Eijkemans MJ, De Klerk C et al. A mild treatmentstrategy for in-vitro fertilisation: a randomised non-inferioritytrial randomized trial. Lancet. 2007;369:743-9.

Nargund G, Frydman R. Towards a more physiological approachto IVF. Reprod Biomed Online. 2007;14(5):550-2.

Nargund G. Natural and Mild assisted reproductive technolo-gies: Reducing cost and increasing safety. Women’s Health(Lond Engl). 2009;5(4):359-60.

Office for National Statistics 2009. (info@statistics.gov.uk)Population Implosion? Low Fertility and Policy Responses in

the European Union. (2005). Rand Corporation ResearchBrief; www.rand.org

Singh S, Darroch JE, Frost JJ. Socioeconomic disadvantage andadolescent women’s sexual and reproductive behaviour: thecase of five developed countries. Fam Plann Perspect.2001;33(6):251-8.

Verberg MF, Macklon NS, Nargund G, Frydman R, Devroey P,Broekmans FJ, Fauser BC. Mild ovarian stimulation for IVF:Review. Hum Reprod Update. 2009;15(1):13-29.

Fig. 1. — Proposed policies to address declining birth rates in developed countries.