When Dr. Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services, recently described American women as “underbabied” in response to the nation’s lowest-ever fertility rate—just under 1.6 births per woman, below replacement—he joined a growing chorus of pundits offering explanations. Their theories range from women’s education and employment to “woke” values, contraception access, environmental toxins, and climate anxiety. But a closer look reveals structural factors unique to the United States that make motherhood less appealing and often unfeasible.
Low birth rates signal labor and care shortages and reflect a society lacking hope for the future, yet the policy conversation has largely missed the core drivers. The U.S. remains the only highly developed country without guaranteed paid leave for new parents or to care for a sick child. While 13 states and the District of Columbia have enacted paid family and medical leave insurance, about 73 million workers still lack access. Even where programs exist, benefits often fall far below salaries, making leave unaffordable for many.
Pregnant workers also face discrimination and unsafe conditions. Although President Biden signed a 2022 law requiring workplace accommodations, the Equal Employment Opportunity Commission’s new chair has slashed reporting requirements and cut the agency’s staff by 25 percent, undermining enforcement. Meanwhile, childcare remains scarce: 36 states face a gap of over 20 percent between available slots and children needing care, and 46 percent of children under six live in a licensed childcare desert. Costs are prohibitive everywhere, consuming large shares of household income even when both parents work.
The wage gap between men and women widens after childbirth, with working mothers’ incomes halved on average and remaining depressed for years. The One Big Beautiful Bill Act now requires Medicaid recipients to be employed, echoing past work requirements that forced mothers of sick children to choose between jobs and care. Abortion restrictions in states like Georgia, Texas, and North Carolina have led to preventable maternal deaths, with studies estimating an 8 percent rise in maternal mortality in those states. Infants with lethal birth defects are often carried to term, contributing to an 11 percent increase in infant deaths in Texas.
These conditions, taken together, don’t make motherhood enticing or even possible for many women. The U.S. is decades late to the global conversation on declining birthrates, having relied on immigration to stay above replacement until recently. International efforts to boost fertility by targeting single issues have failed, suggesting the need for a comprehensive approach. As Wendy Chavkin, MD, MPH, professor emerita at Columbia University, argues, “We could start by comprehensively tackling the many concrete obstacles that make it so difficult to be parents in the U.S.” Chavkin began researching policy responses to declining birthrates 20 years ago and authored The Globalization of Motherhood.
Public opinion reflects deep divisions on these issues. A recent poll found that Republican women are less enthusiastic about America’s 250th anniversary, while another survey shows only 45% of Democrats feel pride in American citizenship. The political landscape is also shifting, with the GOP mapping a legislative offensive after the Supreme Court upheld birthright citizenship, a ruling that exposes deeper divides over national identity. Meanwhile, the U.S.-Iran deal leaves ballistic missiles unchecked, and validates Tehran’s deterrent, adding to the geopolitical anxieties that may also influence family planning decisions.
