The Declining Birth Rate Spurs a Reimagining of a Landmark Family Planning Program

The United States has witnessed a persistent decline in the number of babies born, a trend that has prompted significant shifts in federal policy, particularly concerning the nation’s primary family planning initiative, Title X. New data released by the Centers for Disease Control and Prevention (CDC) indicates that in 2025, the country recorded approximately 3.6 million births, marking a 1% decrease from the previous year. This continues a longer-term trajectory, with the fertility rate now standing at 53.1 births per 1,000 women aged 15 to 44, a substantial 23% drop since 2007.

This demographic shift has captured the attention of the Trump administration, which has publicly expressed a desire to reverse this trend and foster what President Donald Trump has termed "a new baby boom." In pursuit of this goal, administration officials have engaged with external advocates and policy groups to explore a range of potential interventions, from financial incentives like "baby bonuses" to more comprehensive approaches to fertility planning. Concurrently, the administration is undertaking a significant reshaping of Title X, the federal government’s sole program dedicated to family planning services.

For over five decades, Title X has operated as a bipartisan cornerstone of public health, ensuring that low-income women have access to essential reproductive healthcare services, including contraception, screening for sexually transmitted infections, and general reproductive health care, irrespective of their ability to pay. At its zenith, this critical safety net program served upwards of 5 million patients annually. A significant proportion of these clients, approximately six in ten, have reported relying on Title X as their sole source of healthcare in a given year, underscoring its vital role in the lives of vulnerable populations.

The evolving landscape of Title X became evident in early April when the Department of Health and Human Services (HHS) issued a Notice of Funding Opportunity (NOFO) inviting nonprofit organizations to apply for Title X grants for the fiscal year 2027, commencing in October. This extensive 67-page document revealed a notable departure from the program’s traditional focus. While contraception, a cornerstone of Title X for decades, was mentioned, it was framed in a limited context, described as potentially overprescribed and associated with negative side effects, and part of a broader "overreliance on pharmaceutical and surgical treatments."

Instead, the grant notification signals a strategic pivot, moving the program’s emphasis away from broad public health interventions towards a more specialized focus on fertility, family formation, and the management of reproductive health conditions such as polycystic ovary syndrome (PCOS), endometriosis, low testosterone, and erectile dysfunction. While the program will continue to support women in "achiev[ing] healthy pregnancies," a critical aspect of its historical mission – the prevention of unintended pregnancies – is conspicuously absent from the explicit language of the new funding guidelines.

Redefining Family Planning: A Shift in Priorities

This reorientation has drawn sharp criticism from former program officials. Jessica Marcella, who previously oversaw the Title X program as a senior official during the Biden administration, characterized the new funding notice as a "wholesale redefinition of family planning." She expressed concern that the administration is utilizing the established framework of family planning as a vehicle for an "entirely different agenda," particularly in light of President Trump’s past proposals to eliminate Title X altogether.

The administration’s overhaul of Title X unfolds against the backdrop of declining birth rates. However, demographers and fertility researchers suggest that the primary drivers of this decline are multifaceted and largely independent of contraception access. Restricting contraception access, they argue, is unlikely to significantly alter the birth rate trajectory.

Demographic Shifts and the Decision to Parent

Demographer Alison Gemmill of UCLA points to timing-related factors as pivotal in the declining birth rates. "Childbearing is increasingly delayed as part of a broader shift toward later adult milestones, including stable employment, leaving the parental home, and marriage," she explained. Gemmill further noted that most American women still complete their childbearing years with an average of two children, indicating a societal shift towards smaller families rather than a rise in childlessness. This suggests that "having children has become more contingent and more planned," she stated.

The decline observed since 2007, according to researchers, largely reflects women postponing births rather than abandoning the prospect of parenthood altogether. Philip Cohen, a professor of sociology at the University of Maryland, supports this view, stating, "The average number of babies women are having in their whole lives has not fallen. It’s still more than 2.0 for women aged 45."

Economist Phillip Levine of Wellesley College attributes the birth rate decline to evolving societal norms surrounding work, leisure, and parenting. He suggests that efforts to reverse these patterns would be more effective if they focused on making childbearing more desirable, rather than hindering the ability to prevent pregnancies.

When asked about the role of contraception in reducing maternal mortality and how the new funding notice aligns with this goal, HHS press secretary Emily Hilliard issued a statement: "Applicants for the 2027 Title X funding cycle will be expected to align with the administration’s stated priorities in the released Notice of Funding Opportunity. HHS, under the leadership of Secretary Kennedy and President Trump, will continue to support policies that support life, family well-being, maternal health, and address the chronic disease epidemic. HHS remains focused on improving maternal outcomes and ensuring programs are administered consistent with applicable law."

Marcella further elaborated that the new funding notice appears to be influenced by two converging forces: the "Make America Healthy Again" movement, characterized by its skepticism of conventional medicine and emphasis on lifestyle and behavioral interventions, and a "pronatalist agenda" aimed at increasing birth rates through policies that prioritize family formation. The language of the document, she observed, reflects both of these influences, with repeated references to "optimal health" and "chronic disease," while simultaneously downplaying the contraceptive services that have been central to Title X’s mission for half a century.

Clare Coleman, president and CEO of the National Family Planning & Reproductive Health Association, expressed concern that aligning Title X with birth-rate goals shifts the program’s focus from individual decision-making to a government objective. She emphasized that the program "is designed to facilitate access to family planning services, including services to achieve and prevent pregnancy."

A New Focus for Title X

The administration’s policy shifts have been met with approval from conservative organizations. Emma Waters, a senior policy analyst at the Heritage Foundation, who advocates for what she terms "restorative reproductive medicine," views the new funding notice as a positive development, bringing overdue attention to aspects of women’s health that have been neglected.

"I was particularly encouraged to see language that spoke to the delays in diagnosis for conditions like endometriosis, the need for women to practically understand how their cycle and fertility works, and to ensure that real root-cause was promoted through Title X," Waters stated. She described the notice not as a narrowing, but as an expansion of the program’s mission, asserting, "I see this iteration of Title X as the fulfillment of its purpose. The goal was never just ‘more contraception’ but a wholesale empowerment of women to govern their own fertility."

Waters also posits that untreated reproductive health problems may contribute to lower birth rates, suggesting that "one of the interesting aspects of this debate, and one that is often overlooked, is the degree to which painful and unaddressed reproductive health problems may suppress or create ambivalence around a woman’s desire to have kids." She specifically pointed to endometriosis as an example.

While an estimated 5% to 10% of women of reproductive age have endometriosis, and 30% to 50% of those experience infertility, the scientific relationship between the condition and infertility is complex and not fully understood. Researchers note that the disease may be more prevalent than recognized, and treatments do not reliably restore fertility. Furthermore, infertility rates in the U.S. have remained relatively stable between 1995 and 2019, even as the national birth rate has declined, suggesting that untreated reproductive disease is not a primary driver of the birth rate drop.

In February, the American College of Obstetricians and Gynecologists (ACOG) released new clinical guidelines aimed at facilitating earlier diagnosis of endometriosis without surgery. However, the first-line treatment recommended by ACOG is hormonal therapy, a category of care that the Title X funding notice appears to de-emphasize. This creates a potential contradiction where the program prioritizes the diagnosis of conditions like endometriosis while appearing to sideline the pharmaceutical treatments clinicians use to manage them.

Crucially, treatments that have demonstrated effectiveness in improving fertility for women with endometriosis, such as laparoscopic surgery and in vitro fertilization (IVF), are not covered by Title X. When President Richard Nixon signed Title X into law in 1970, the stated intent was to expand access to family planning services, empowering women to determine the number and spacing of their children through increased availability of contraception and related preventive care, particularly for those unable to afford it. While Medicaid serves as the primary government health insurance program for low-income women, it, like many commercial insurance plans, does not cover IVF.

Liz Romer, a former chief clinical adviser for the HHS Office of Population Affairs, acknowledged that many of the conditions prioritized in the new funding notice warrant attention. However, she argued that they fall outside the scope of what Title X can realistically address. "There’s not even enough funding to support the core premise of contraception," Romer stated. "And so, if you want to expand Title X funding, you can expand the scope, but you can’t move away from the foundation."

The emergence of an ideology that appears to question or de-emphasize contraception within federal health policy is particularly striking, given broad public support for birth control access. A 2024 survey by KFF revealed that eight in ten women of childbearing age reported using some form of contraception in the preceding 12 months.

Laura Lindberg, director of the Concentration in Sexual and Reproductive Health, Rights and Justice at Rutgers School of Public Health, warned that sidelining contraception in Title X will translate into tangible consequences for patients. "If contraception is sidelined in Title X, it won’t just change language on paper but will show up as fewer options and more barriers for patients," she stated. Lindberg also expressed concern that funding might shift away from providers offering comprehensive contraceptive care towards organizations that are ideologically opposed to contraception and may not deliver the same standard of health services.

High Stakes for Public Health

The United States already grapples with one of the highest maternal mortality rates among wealthy nations, with 17.9 deaths per 100,000 live births as of 2024, according to the CDC. Research indicates that approximately four in five pregnancy-related deaths in the U.S. are preventable. Medical evidence demonstrates that pregnancy carries significantly higher risks of serious complications, such as blood clots, stroke, and cardiovascular issues, compared to hormonal contraception.

Furthermore, since the Supreme Court’s 2022 decision in Dobbs v. Jackson Women’s Health Organization, which overturned the constitutional right to abortion established by Roe v. Wade, access to abortion has been severely curtailed in many parts of the country. While national abortion numbers have seen an increase, largely attributed to telehealth and interstate access, studies indicate a rise in births in states with abortion bans, resulting in an estimated 32,000 additional births annually, disproportionately affecting young women and women of color.

Dr. Christine Dehlendorf, director of the Person-Centered Reproductive Health Program at the University of California-San Francisco, asserted that "there is absolutely no evidence for any positive outcome of restricting access to contraception." She warned that such restrictions would likely lead to an increased demand for abortion care and make it more challenging for women to prevent high-risk pregnancies.

Since the Trump administration’s return to office, more than a dozen Title X grantees have experienced frozen grants, forcing some health centers to cease services, lay off staff, or close entirely. During the first Trump administration, regulatory changes led to a significant decline in Title X participation, from over 4 million patients to approximately 1.5 million. The program saw a slow recovery under the Biden administration, reaching about 3 million clients, before the current round of disruptions began.

Marcella concluded that the second Trump administration’s overhaul of the program "directly undermines the public health intent of our nation’s family planning program and will potentially exclude millions of individuals from getting the care they have relied on for decades. It’s bad policy." The implications of these policy shifts extend beyond administrative changes, potentially impacting the health and reproductive autonomy of millions of Americans.