Authors: Mallory Johnson, Rhea Manohar, MPH, Meghan Etsey, Teresa Lazar on behalf of AMWA’s Gender Equity Task Force
Picture a young couple scrolling through city apartments, their conversation caught between soaring rents, student loan payments, and whether they could even fit a child into their carefully budgeted lives. This scene is no longer unusual. Across the globe, people are choosing to have fewer children with the current total fertility rate in the United States standing at 1.6 children per woman—a rate that is predicted to stay stable until 2100 according to global population metrics (Pew Research Center, 2023). Notably, this rate falls well below the replacement level of 2.1 needed to maintain a stable population, which reflects a global shift towards a population that is not only aging, but also imbalanced without enough individuals in the working class to support it (Pew Research Center, 2023). Northern America, Europe, Asia, and Latin America are all experiencing similar declines, while Africa remains the only region with fertility rates above replacement level.
The reasons are layered, but money is often the first challenge that comes to mind—and for good reason. Housing, childcare, and day-to-day living costs continue to rise, while job security and wages stagnate. A variety of sources have estimated that the average cost of raising a child annually drastically increased by 19% from 2016 to 2023. To put this in perspective, the cost for raising a child through the first 17 years of life is estimated to be between $300,000 – $400,000 dollars (Braun-Silva, 2025). Globally, nearly 40% of people cite financial constraints as the primary reason they are not having as many children as they would like (UNFPA, 2025). In an effort to address the declining birth rate, governments have tried offering incentives like baby bonuses or expanded maternity care. Even countries with generous family policies, like Norway or Japan, are experiencing declining birth rates, showing that cultural expectations often outpace policy solutions. While these provide a partial alleviation of the cost of child rearing, research suggests that long-term, structural support—affordable childcare, paid parental leave, and gender-equitable workplaces—has a far greater impact on fertility decisions.
Careers and lifestyle aspirations further complicate the equation. Women today are attaining higher education and professional growth at unprecedented rates, which is universally considered a triumph for both public health and gender equity. Yet this progress intersects with demanding dual-income household norms and evolving labor market dynamics in ways that complicate long-term family planning. A growing body of research shows that higher labor-force participation, especially in professional “abstract” careers, is linked with postponed childbearing—partly due to opportunity costs and the rapid pace of skill obsolescence during early motherhood (Shreffler et al., 2013; Doepke, 2023). The so-called “competing devotions” of career and parenthood create a real trade-off: even women who deeply value motherhood often delay or forgo it when career progression looms large (Shreffler et al., 2013). One example of this impact is seen for women physicians, with one study reporting that 1 in 4 reported infertility. For women physicians, both the grueling nature of the extensive medical training as well as biases and discrimination in training opportunities and growth lead to delays in child-bearing (Simpson et al., 2021). Gig economy jobs and inflexible workplaces add yet another layer of complexity. While the gig sector offers flexible hours, this flexibility comes with gendered burdens of unpaid care (Khan et al., 2023). Even middle-class women with stable jobs face compounding pressures: the dual burden of paid work and unpaid caregiving, exacerbating stress and sleep loss while reducing fertility intentions.
These challenges were magnified during the COVID-19 pandemic, which intensified the fragility of existing systems. Many women faced longer work hours, insufficient parental benefits, and unstable schedules on top of fluctuating economic conditions (Ro, 2020). This created a landscape where starting a family can feel less like a choice and more like a luxury few can afford. At the same time, cultural attitudes toward parenthood are shifting. Surveys show that many young adults now prioritize personal fulfillment, social connections, and career over parenthood, reflecting a broader reordering of life priorities (Kearney & Levine, 2025). Health and access challenges complicate that picture further. Awareness of age-related fertility decline, uneven access to reproductive healthcare, and inconsistent parental leave policies shape decisions about if and when to have children. In combination with economic pressures and cultural norms, these barriers make family planning a high-stakes, high-stress endeavor.
The consequences of declining fertility rates are significant. Smaller workforces, rapidly aging populations, and strains on healthcare and social systems threaten the stability of entire nations. Addressing these challenges requires holistic solutions: policies that make parenting feasible, workplaces that enable flexibility, and societal shifts that share caregiving responsibilities more equitably. Only by tackling these barriers can families thrive—and only then can we secure a sustainable, balanced future for the next generation.
References
- Braun-Silva, B. (2025, April 7). How much it costs to raise a child in the US. ABC News. https://abcnews.go.com/GMA/Family/costs-raise-child-us/story?id=120376717
- Doepke, M., Hannusch, A., Kindermann, F., & Tertilt, M. (2023). Chapter 4 – The economics of fertility: a new era. ScienceDirect. https://www.sciencedirect.com/science/article/am/pii/S1353829218312243
- Khan, M. H., Williams, J., Williams, P., & Mayes, R. (2023). Caring in the Gig Economy: A Relational Perspective of Decent Work. Work, Employment and Society, 38(4), 1107-1127. https://doi.org/10.1177/09500170231173586
- Pew Research Center. (2023). 5 facts about declining fertility rates around the world. https://www.pewresearch.org/short-reads/2025/08/15/5-facts-about-global-fertility-trends/
- Shreffler, K. M., & Johnson, D. R. (2013). Fertility Intentions, Career Considerations and Subsequent Births: The Moderating Effects of Women’s Work Hours. Journal of family and economic issues, 34(3), 285–295. https://doi.org/10.1007/s10834-012-9331-2
- United Nations Population Fund (UNFPA). (2025). Global survey on family planning and fertility trends. https://www.unfpa.org/swp2025
- Kearney, M. S., & Levine, P. B. (2025). Shifting priorities: Parenthood and modern adulthood. National Bureau of Economic Research.
- Ro. (2020). Modern State of Fertility 2020: Career + money. https://ro.co/fertility/fertility-survey-2020
- Simpson, A. N., Cusimano, M. C., & Baxter, N. N. (2021). The inconvenience of motherhood during a medical career. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 193(37), E1465–E1466. https://doi.org/10.1503/cmaj.211255
About the Authors
Mallory Johnson, MS4
Mallory Johnson is a fourth-year medical student from St. George’s University. She holds a Bachelor of Science in Forensic Science and a Bachelor of Science in Chemistry from Tiffin University. She worked as an Analytical Chemist at P&G and KAO before medical school. She is passionate about giving back to vulnerable communities and providing equal access and opportunity to medical care. She is a member of the Domestic Violence and Music in Medicine Committees within the American Medical Women’s Association. When she’s not doing schoolwork, you can find her playing her cello, reading cozy mysteries, and playing with her poodles, Gertie and Maple.
Rhea Manohar, MPH, MS3
Rhea Manohar is a third year medical student from St. George’s University. She has a Masters in Public Health with a concentration in Maternal and Child Health from George Washington University Milken Institute of Public Health and a Bachelors of Science in Microbiology, Immunology, and Public Health from the University of Miami. She served as Co-VP of OB/GYN Education for St. George’s University’s Women in Medicine chapter in St. George, Grenada where she developed and implemented hands-on workshops to further reproductive health issues and bolstered medical students abilities to navigate physician-patient communication. Prior to medical school, she was a Research Associate for Fors Marsh Group, where she led qualitative and quantitative public health research and campaign development for federal agencies (e.g., CDC, NIH, DHHS, CPSC). She is also a member of the Gender Equity Task Force and Reproductive Health Coalition within the American Medical Women’s Association. When she is not pursuing medicine, you can find her reading, exploring artistic passions, and spending time connecting with friends and family.
Meghan Etsey, MS4
Meghan Etsey is a fourth year medical student from St. George’s University. She has a Bachelors of Arts in Biology and a Bachelors of Arts in Nutrition and Dietetics from Bluffton University in Bluffton, Ohio. She served as the President of the St. George’s University’s Women in Medicine chapter in St. George, Grenada where she expanded relationships with the community and worked towards educating women and helping the youth. She is also a member of the Gender Equity Task Force and Sex and Gender Health Collaborative Committees within the American Medical Women’s Association. When she is not pursuing medicine, you can find her with her friends and family on different road trips and adventures exploring the world.
Teresa Lazar, MD MSEd is the clerkship director of the Advanced Clinical Experience in Obstetrics and Gynecology and Assistant Professor at the Donald and Barbara Zucker School of Medicine at Hofstra Northwell (ZSOM). She obtained her medical degree and completed her residency in obstetrics and gynecology from the State University of New York Health Science Center in Brooklyn and graduated with a Master of Science in Education degree in health professions from Hofstra University. Dr. Lazar was recognized with the APGO Excellence in Teaching Award and is a member of the Academy of Medical Educators and Alpha Omega Alpha Honor Medical Society at the ZSOM. Currently, a member of the American Medical Women’s Association Gender Equity Task Force and the Education Committee. Dr. Lazar is board certified by the American Board of Obstetrics and Gynecology, areas of clinical interest include general obstetrical care, gynecologic care and pelvic ultrasounds. Additionally, she is passionate about medical education, faculty development, communication, and leadership. She is fluent in both English and Spanish.