The number of babies born last year in the United States dropped again.
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According to the Centers for Disease Control and Prevention (CDC), there will be 3.6 million births by 2025, which is a 1% decrease from 2024. The fertility rate fell to 53.1 births for every 1,000 women aged 15 to 44. This is a 23% drop since 2007.
The Trump administration has stated that it wants to reverse the trend. President Donald Trump called for a “new baby boom,” while aides solicited proposals ranging from baby bonus to expanded fertility planning from outside groups and advocates. The administration also proposes to reshape Title X, the federal government’s sole family planning program.
Title X, which has enjoyed bipartisan support for more than 50 years, is geared toward providing low-income women with access to contraception, screenings for sexually transmitted diseases, and reproductive health services, regardless of their ability to pay. The safety net program served over 5 million patients per year at its peak. Six out of ten Title X clients reported that the program was their only source of health care during a given calendar year.
The Department of Health and Human Services invited non-profit organizations to apply for Title X Grants for the fiscal year 2027 that begins in October. The 67-page Notice of Funding Opportunity made only one mention of contraception, describing it as being overprescribed and associated with negative side effects. It also said that it was part of an overall “overreliance on surgical and pharmaceutical treatments.”
The grant notification reshapes program efforts from its traditional public-health intervention efforts and focuses on fertility, family formation and reproductive health conditions, such as polycystic Ovarian Syndrome, endometriosis and low testosterone.
Title X continues to help women achieve “healthy pregnancies,” but the grant document does mention explicitly preventing unintended pregnancy, a long-standing program goal.
Jessica Marcella, a senior official who oversaw Title X as part of the Biden administration said that the new funding notice amounts a wholesale redefining of family planning.
“What we are seeing is an attempt to use our nation’s Family Planning as a Trojan Horse for an entirely separate agenda,” Marcella said. She noted that Trump has proposed removing Title X completely.
Birth Rates and Fertility trends
Title X is being reformed by the administration in response to declining birth rates. Researchers who study fertility trends claim that the decline in birth rates is not due to contraception and that limiting access to it will not increase births.
According to demographer Alison Gemmill at UCLA, timing is the most important factor. “Childbearing has become increasingly delayed, as part of an overall shift towards later adult milestones such as stable employment, leaving parental home and marriage,” she said.
She said that most American women still finish their childbearing year with an average two children. This suggests a shift towards smaller families, rather than an increase of childlessness.
She said, “Having children has become more contingent as well as more planned.”
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The decline in births since 2007 is largely due to women delaying their babies rather than abstaining from them.
“The average number that women have in their lifetime has not decreased.” It’s still over 2.0 for women age 45, said Philip Cohen a professor of Sociology at the University of Maryland.
Phillip Levine, an economics professor at Wellesley College said that the birth rate is down due to changes in the way women approach work, play, and parenting. “Efforts that reverse these patterns will be more successful if we can make childbearing desirable, rather than make it harder to avoid a pregnancy,” said Phillip Levine, an economist at Wellesley College.
Emily Hilliard, HHS Press Secretary, responded to a question about the role of contraception and maternal mortality reduction. She said that the new funding notice would advance this goal. Under the leadership of Secretary Kennedy, and President Trump, HHS will continue to support policies which support life, family health, maternal health and address the chronic diseases epidemic. HHS remains focused to improve maternal outcomes and ensure programs are administered in accordance with applicable laws.”
Marcella said that the new funding notice was the result of two forces coming together: the Make America Healthy Again (MAHA) movement, which is sceptical of conventional medicine, and places an emphasis on lifestyle and behavioral intervention, and the pronatalist agenda, which aims to increase birth rates through policy geared toward family formation.
The document’s wording reflects both: it repeatedly invokes “optimal” health and “chronic” disease, while ignoring the contraceptive services which have defined Title X over half a century.
Clare Coleman is the president and CEO of National Family Planning & Reproductive Health Association. The organization represents health professionals who are focused on family planning. She said that tying Title X with birth-rate goals would replace individual decision-making by a government goal. She said the program was designed to “enable access to family planning services including services to achieve or prevent pregnancy.”
Title X’s New Focus
Right-wingers have welcomed the administration’s changes.
Emma Waters, senior policy analyst with the conservative Heritage Foundation who has advocated what she calls “restorative reproduction medicine,” said that the new funding notice reflects the long overdue attention given to neglected aspects of women’s health.
Waters said that she was “particularly encouraged” to see the language that addressed the delay in diagnosing conditions like endometriosis and the need for women understand their cycle and fertility. She also emphasized the importance of promoting the real root cause through Title X.
She described the notice, not as a narrowing of the program, but as an expansion of its mission: “I view this iteration as the fulfillment of Title X’s purpose.” The goal was not just “more contraception” but rather a wholesale empowerment for women to control their own fertility.
Waters also argued untreated reproductive health issues may contribute to a lower birth rate.
“One of the fascinating aspects of this debate and one that is often ignored, is the extent to which painful and unaddressed reproduction health problems can suppress or create ambivalence about a woman’s wish to have children,” she said. She referred to endometriosis.
Endometriosis affects 5% to 10% women in reproductive age. Of those, 30-50% are infertile. The relationship is not proven, but it’s an association. Women who don’t show symptoms are not screened for endometriosis, and it may be more common than we realize. Researchers are still unsure why some women with Endometriosis have difficulty conceiving, while others don’t. Treating the disease doesn’t always restore fertility.
Infertility rates have not increased in the U.S. An analysis of federal data showed that they were essentially flat from 1995 to 2019, despite the sharp decline in national birth rates.
In February, the American College of Obstetricians and Gynecologists released new clinical guidelines that allow earlier diagnosis of endometriosis, without surgery. This is a step towards addressing the delays Waters describes. The first-line treatment ACOG suggests is hormonal therapy. This is part of the same category as the funding notice, which dismisses it as part of “an overreliance on pharmaceutical and surgery treatments.”
Title X does not cover treatments that have been proven to improve fertility for women with endometriosis. These include laparoscopic surgery and IVF. Title X was signed into law by President Richard Nixon in 1970. He described it as a means to increase access to family planning, helping women to determine the number of children and their spacing, and making contraception and related prevention care more widely accessible, especially for those who couldn’t afford it. Medicaid, and not Title X is the primary government-funded health insurance program for low-income women. However, it does cover IVF, as do many commercial insurance plans.
Liz Romer, former chief clinical advisor for the HHS Office of Population Affairs, who helped update guidelines for the Family Planning Program, said that many of the conditions prioritised in the funding notification deserve attention. Title X cannot provide for them.
Romer said that there was not enough funding to support contraception’s core premise. “If you want to increase Title X funding, then you can expand its scope, but not the foundation.”
She said that the emergence of a anticontraception philosophy within federal health policies is striking, given how widely birth control is supported by the public. Eight out of ten women of childbearing years surveyed by KFF 2024 reported using some form of contraception within the past 12 months.
Laura Lindberg, director of Rutgers School of Public Health’s Concentration in Sexual, Reproductive Health, and Rights and Justice, said that if contraception were to be sidelined, it would not only change the language on paper, but also result in fewer options for patients and more barriers. “Funding could shift away from providers offering a full range of care and towards organizations that are ideologically against contraception and do not deliver the same level of health care services.”
The stakes are high
As of 2024, the United States has one of highest maternal mortality rates of all wealthy nations – 17.9 deaths for every 100,000 live births. According to the CDC 4/5 of pregnancy-related deaths that occur in the U.S. could be prevented. According to medical research, pregnancy is associated with a higher risk of blood clots and strokes, as well as cardiovascular complications.
Since the Supreme Court’s Dobbs ruling in 2022 that overturned the constitutional rights to abortion established by Roe v. Wade has significantly reduced access to abortion across most of the United States. While abortion numbers in the United States have increased, largely due to telehealth and interstate accessibility, research shows that births have increased, with an estimated 32,000 extra births per year, disproportionately among women of color and young women.
Dr. Christine Dehlendorf of the Person-Centered Reproductive Health Program of the University of California-San Francisco said, “There is absolutely no evidence that restricting access would have a positive outcome.” Instead, restrictions would increase the demand for abortion services and make it more difficult for women to avoid high-risk pregnancy.
Since Trump’s return to office, the grants of more than a dozen Title X grantees were frozen. This forced some health centers to stop providing services, layoff staff, or even close. During the first Trump Administration, regulatory changes caused a drop in Title X participation. From more than 4,000,000 patients to only 1.5 million. The program grew slowly during the Biden administration and reached about 3 million clients before the current round was introduced.
Marcella said that the second Trump administration’s overhaul to the program “directly undermines public health intentions of our nation’s Family Planning Program and will potentially exclude million of individuals from receiving the care on which they have relied for decades. It’s bad.”
Celine Gounder
cgounder@kff.org
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