Baby boom is baby bust as post-lockdown birth rates take a dive

Published 09 April 2021

Birth rates in some Mediterranean countries have fallen dramatically in the first months of 2021, prompting speculation that ever-shrinking fecundity might signal economic hardship ahead. Can IVF help?

It is now more than nine months since the first COVID-19 lockdowns were ordered, and with them the speculated likelihood of a new baby boom. What else was there to do?

Think again. The latest figures from three Mediterranean countries have shown remarkable declines in rates of childbirth in the first months of 2021, suggesting that a baby-bust was the lockdown norm, not a baby boom. Italy, for example, where population has been steadily shrinking since 2017, witnessed a dramatic decline in births throughout 2020 – from 420,000 in 2019 to around 400,000, according to the country’s national statistics agency ISTAT. Even in 2019 total fertility rate in Italy was as low as 1.27, and this languishing level now looks set to fall even further this year. The latest figures from the agency show that Italy recorded 21.6% fewer births in December 2020 — nine months after the country went into lockdown — than in December 2019.

Similarly in France, where a long history of pro-population policies has been behind fertility rates higher than in other European countries, the national statistics institute has provisionally reported 13% fewer births in January 2021 than in January 2020. This, according to INSEE, has led to France’s biggest fall in births since the 1970s and the lowest number of total births since the 1940s. And in Spain too a press release of 10 March from the national statistical institute reported that the number of births had declined by 20% in December and January when compared with the same months a year before. These were data, said to INE, recorded ‘within the context of COVID-19’. The December/January figures from Spain show a remarkably steeper decline in childbirth than in all other months of 2020.

The dramatic fall in birth rates seen in Spain, Italy and France are not, however, apparent throughout the north of Europe or elsewhere in the world. Sweden, for example, recorded a more modest 6% drop in the number of births in January, according to figures from the country’s statistics office, while the Netherlands and Finland both appeared to reverse years of childbirth decline in January. Overall, this marginal difference in fertility trends in north and southern Europe is a pattern evident for several years, usually explained by social and political factors but now apparently intensified by the COVID pandemic.

The usual explanations for a fall in fertility rate have been better work opportunities for women, a greater domestic reliance on two incomes and delayed plans to start families. France, which has traditionally had the highest fertility rate in Europe (1.84 children in 2018), has additionally offered financial, childcare and other pro-natalist incentives, but like other European countries has also seen its average maternal age at childbirth recently increase to over 30 years.

In those countries which in the past few months have added an escalating COVID-explained mortality rate to their fast falling birth rates, the economic outlook could be catastrophic. In Italy, for example, the divergence between absolute numbers of births and deaths is at an extreme, and growing further and further apart. The Financial Times newspaper, which keeps an economist’s eye on these trends, speculated that if fertility rates continued to fall ‘it would have profound implications for economies and societies, affecting everything from immigration to education and pensions’.(1) Indeed, the Domesday scenario highlighted in a Lancet report in 2018 had even then found that half the 195 countries studied were recording insufficient births to maintain population levels.(2,3)

Could IVF help? ESHRE’s annual EIM reports have shown for many years a direct association between state funded/reimbursed IVF, accessibility to treatment and uptake. Countries like Belgium, Denmark and Slovenia have long illustrated the link between the proportion of children conceived by IVF (as in classroom demographics, for example) and funding. So there does seem a correlation. However, a 2017 United Nations paper on population policies, while citing baby bonuses, family allowances, maternal and paternal leave, tax incentives and flexible work schedules as effective policy measures, made no mention of funded fertility treatment. Yet Denmark, with its generous state funding of IVF, could regularly boast that some 5% of children in any given classroom were IVF.

Moreover, with such possibilities in mind, the prime minister of Japan, where fertility rates have been in freefall since the 1970s (and stood at 1.36 in 2019), announced last year that IVF would be covered by national health insurance.(4) The policy, he said, was explicitly a ‘countermeasure to the falling birth rate’. In 2018 there were around 57,000 IVF births in Japan, which, according to one researcher, ‘could increase to 100,000 if covered on insurance’.

The other question, of course, is whether IVF would work as well as anticipated in the population of women now deferring childbirth. The average age of first-time mothers is now around 30 years in most developed countries, and still climbing. National statistics, as in the Netherlands, for example, show fewer and fewer ‘young’ (20-30 years) mothers - and with first-time births now well over 30 years in Spain and Italy. However, with most babies in Europe now born to mothers aged between 30 and 34 there will inevitably be many beyond those ages whose ovarian reserve has diminished beyond recall. With such ubiquitous trends in fertility rates and motherhood age, many cases will simply be untreatable except by egg donation. Poor response to ovarian stimulation has proved one of the most intractable challenges of IVF, with increased dose or adjuvant therapies of little benefit. As ESHRE’s latest EIM report (and every other registry) reaffirms, the decline in success rates is age-dependent for IVF and ICSI, and, for women aged 40 years and older, ranges between 0% and 13% in EIM data.

Nevertheless, despite the demographic trends and the implications of age-related infertility, studies consistently show that lower levels of state-funding are correlated with higher unmet needs for treatment, while more generous reimbursement policies increase access to treatment and may even make a measurable contribution to national birth rates. This may be more important than ever with the decline in post-lockdown birth rates.

1. See https://www.ft.com/content/bc825399-345c-47b8-82e7-6473a1c9a861
2. Vollset SE, Goren E, Yuan C-W, et al. Fertility, mortality, migration, and population scenarios
for 195 countries and territories from 2017 to 2100:
a forecasting analysis for the Global Burden of Disease Study. Lancet 2020; doi.org/10.1016/S0140-6736(20)30677-
3. See https://www.focusonreproduction.eu/article/News-in-Reproduction-Population
4. See https://www.ft.com/content/2eba0372-298b-4027-ac83-bf191e7d60aa

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