The number of babies born in the United States declined again in 2025. New CDC data show 3.6 million births last year, a 1% drop from 2024, and a fertility rate of 53.1 births per 1,000 women ages 15 to 44 — down 23% since 2007.
The Biden-era family planning program Title X, long focused on providing low-income people with contraception, STI screening, and reproductive care regardless of ability to pay, is at the center of a proposed overhaul by the Trump administration. In early April, HHS invited nonprofit organizations to apply for 2027 Title X grants. The 67-page Notice of Funding Opportunity mentions contraception only once, characterizing it as overprescribed and part of an “overreliance on pharmaceutical and surgical treatments,” and reframes the program toward fertility, family formation, and conditions such as polycystic ovary syndrome, endometriosis, low testosterone, and erectile dysfunction. The notice says Title X will continue to help women “achieve healthy pregnancies” but omits explicit reference to preventing unintended pregnancies, a long-standing goal of the program.
Advocates and former officials say the change amounts to a wholesale redefinition of family planning. Jessica Marcella, who oversaw Title X under the Biden administration, called the funding notice a “Trojan horse” for an agenda that could sideline contraceptive services. The administration has also proposed eliminating Title X entirely.
Experts who study fertility trends argue that declining birth rates largely reflect delayed childbearing rather than lack of contraceptive access. Demographer Alison Gemmill of UCLA emphasizes timing: childbearing is increasingly postponed as people delay marriage, stable employment, and other adult milestones. Sociologist Philip Cohen noted many women still complete childbearing with about two children, suggesting a shift to smaller families rather than widespread childlessness. Economist Phillip Levine said policies aiming to increase births would be more effective by making childbearing more desirable than by restricting pregnancy prevention.
HHS press secretary Emily Hilliard said applicants for the 2027 Title X cycle must align with the administration’s priorities, adding that HHS will “continue to support policies that support life, family well-being, maternal health, and address the chronic disease epidemic” and will administer programs consistent with law.
Supporters of the new direction praise attention to underdiagnosed reproductive conditions. Emma Waters of the Heritage Foundation said the notice appropriately emphasizes delays in diagnosing conditions like endometriosis and educating women about fertility. She described the change as expanding Title X’s mission to empower women to govern their fertility and suggested untreated reproductive health problems could contribute to lower birth rates.
But clinicians and reproductive health groups say the shift contains contradictions and practical limits. Endometriosis, which may affect 5% to 10% of reproductive-age women and can be associated with infertility in some cases, has been cited as a condition needing greater attention. The American College of Obstetricians and Gynecologists recently issued guidance enabling earlier endometriosis diagnosis without surgery, but ACOG’s recommended first-line treatment is hormonal therapy — exactly the category of care the Title X notice criticizes. Treatments that can improve fertility for those with endometriosis, like laparoscopic surgery and IVF, are not covered by Title X.
Clare Coleman, president and CEO of the National Family Planning & Reproductive Health Association, warned that tying Title X to birth-rate goals replaces individual decision-making with a government objective. Liz Romer, a former chief clinical adviser for the HHS Office of Population Affairs, said many conditions in the notice deserve attention, but Title X lacks the funding and scope to provide them without undercutting its contraception foundation.
Public opinion and use patterns complicate the picture. KFF polling in 2024 found eight in 10 women of childbearing age had used some form of contraception in the previous 12 months. Laura Lindberg of Rutgers warned that sidelining contraception in Title X could mean fewer options and more barriers for patients, as funding might shift toward organizations ideologically opposed to contraception and away from providers offering the full range of contraceptive care.
The stakes extend beyond birth rates. The U.S. has one of the highest maternal mortality rates among wealthy nations — 17.9 deaths per 100,000 live births as of 2024 — and the CDC estimates that about 4 in 5 pregnancy-related deaths in the U.S. may be preventable. Medical research shows pregnancy carries substantially higher risks (blood clots, stroke, cardiovascular complications) than hormonal contraception. Since the Supreme Court’s 2022 Dobbs decision overturning Roe v. Wade, abortion access has been curtailed in many states; estimates indicate about 32,000 additional births annually in states with bans, disproportionately affecting young women and women of color. Dr. Christine Dehlendorf of UCSF said there is “absolutely no evidence for any positive outcome of restricting access to contraception,” and that such restrictions would increase demand for abortion care and make it harder to prevent high-risk pregnancies.
Title X’s history and recent disruptions are relevant. Signed into law in 1970, Title X was created to expand access to family planning services so women could determine the number and spacing of children. At its peak, the program served more than 5 million patients a year, and roughly six in 10 Title X clients have reported using it as their only source of health care in a given year. Under the first Trump administration, regulatory changes led Title X participation to fall from over 4 million patients to about 1.5 million. The program grew to about 3 million clients under Biden, but since President Trump returned to office, more than a dozen grantees have had grants frozen, forcing some health centers to halt services, lay off staff, or close.
Reproductive health researchers note that infertility rates in the U.S. have remained essentially flat between 1995 and 2019, even as the national birth rate fell — a divergence suggesting untreated reproductive disease is not the primary driver of the overall decline. That, critics say, undermines the premise that de-emphasizing contraception in Title X will boost births.
Advocates for maintaining contraceptive access argue that the program’s original public health intent — preventing unintended pregnancies, reducing maternal risk, and providing preventive reproductive care — would be undermined by the proposed shift. Jessica Marcella said the overhaul “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.”
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