U.S. birth numbers fell again in 2025, continuing a longer-term downward trend. New CDC figures show about 3.6 million births last year, a roughly 1% decline from 2024, and a total fertility rate of 53.1 births per 1,000 women aged 15 to 44 — about 23% lower than in 2007.
The federal family planning program Title X, historically focused on providing low-income people with contraception, sexually transmitted infection screening, and other reproductive care regardless of ability to pay, is the focus of a proposed retooling by the Trump administration. In early April, the Department of Health and Human Services opened a 67-page Notice of Funding Opportunity inviting nonprofits to apply for 2027 Title X grants. Contraception is mentioned only once in the document, portrayed as being overprescribed and part of an “overreliance on pharmaceutical and surgical treatments.” Instead, the notice pivots Title X language toward fertility, family formation, and medical conditions such as polycystic ovary syndrome, endometriosis, low testosterone, and erectile dysfunction. It promises continued help for women to “achieve healthy pregnancies,” but drops explicit language about preventing unintended pregnancies, a central aim of the program for decades.
Advocates and former officials contend the change amounts to a fundamental redefinition of public family planning. Jessica Marcella, who managed Title X during the Biden administration, called the funding notice a “Trojan horse” that could marginalize contraceptive care. The administration has also floated proposals to eliminate Title X entirely.
Researchers who study fertility trends say the falling birth rate is driven chiefly by delayed childbearing rather than lack of contraceptive access. Demographer Alison Gemmill of UCLA points to timing factors: many people postpone childbearing while they delay marriage, seek stable jobs, or reach other milestones. Sociologist Philip Cohen notes that although people are having children later, many still end up with roughly two children over their lifetimes, suggesting smaller or later families rather than mass childlessness. Economist Phillip Levine argues policies intended to raise birth rates would be more effective if they made parenting more appealing — for example, through economic supports — rather than by restricting access to pregnancy prevention.
An HHS spokesperson said applicants in the 2027 Title X round must align with the administration’s priorities. The agency emphasized support for “life, family well-being, maternal health,” and addressing chronic disease, and said it will administer programs in accordance with the law.
Supporters of the administration’s approach welcome more attention to underdiagnosed reproductive conditions. Emma Waters of the Heritage Foundation called the funding notice a proper emphasis on diagnosing conditions such as endometriosis earlier and on educating women about fertility, describing the change as expanding Title X’s mission to help women manage their reproductive health. She suggested that untreated reproductive problems may contribute to lower birth rates.
Clinicians and reproductive health groups say the notice is contradictory in places and limited in scope. Endometriosis, which may affect 5% to 10% of people of reproductive age and can be associated with infertility for some, is frequently cited as a condition needing better detection. The American College of Obstetricians and Gynecologists has issued guidance to enable earlier diagnosis of endometriosis without surgery, but its recommended first-line treatment is hormonal therapy — the very kind of care the HHS notice critiques. Procedures that can improve fertility for people with endometriosis, such as laparoscopic surgery or in vitro fertilization, are outside the Title X program’s coverage.
Leaders of reproductive health organizations warn of broader consequences if Title X is refocused on population targets. Clare Coleman, president and CEO of the National Family Planning & Reproductive Health Association, said tying Title X to birth-rate objectives would substitute a government target for individual decisions about family size. Liz Romer, a former chief clinical adviser at the HHS Office of Population Affairs, agreed that many conditions singled out in the notice merit greater attention, but she cautioned that Title X lacks the funding and clinical capacity to take those on without eroding its contraception services.
Public opinion and usage patterns complicate the argument that contraceptive access is driving the birth decline. KFF polling in 2024 found about eight in 10 women of childbearing age had used some form of contraception in the prior year. Laura Lindberg of Rutgers warned that deprioritizing contraception within Title X could reduce options and raise barriers, as funding might shift toward organizations that are ideologically opposed to contraception and away from clinics that provide a full range of contraceptive methods.
The stakes extend beyond birth-rate statistics. The United States has one of the highest maternal mortality rates among wealthy countries — 17.9 deaths per 100,000 live births as of 2024 — and the CDC estimates that roughly four in five pregnancy-related deaths in the U.S. may be preventable. Medical research shows that pregnancy carries substantially higher risks, including blood clots, stroke, and cardiovascular complications, than the risks associated with hormonal contraception. Since the Supreme Court’s 2022 Dobbs decision rescinding Roe v. Wade, abortion access has been restricted in many states; researchers estimate about 32,000 additional births annually in states that have imposed bans, with disproportionate impacts on young people and women of color. Dr. Christine Dehlendorf of UCSF said there is no evidence that restricting contraception produces better outcomes and warned such policies would increase both the demand for abortion care and the difficulty of preventing high-risk pregnancies.
Title X’s origins and recent disruptions provide context for the current debate. Created by Congress in 1970 to expand access to family planning so people could determine the number and spacing of their children, Title X once served more than 5 million patients a year. At its peak under earlier administrations, the program had over 4 million clients; regulatory changes under the first Trump administration reduced participation to about 1.5 million. The program rose to roughly 3 million clients during the Biden years, but since President Trump returned to office, over a dozen grantees have had grants frozen, forcing some health centers to pause services, lay off staff, or close.
Reproductive health researchers also note that infertility rates in the U.S. have been largely flat between 1995 and 2019, even as birth rates fell — a divergence that undercuts the idea that untreated reproductive disease is the primary cause of the overall decline in births. Critics say this weakens the premise that deemphasizing contraception in Title X will meaningfully increase births.
Proponents of preserving Title X’s contraceptive focus argue the program’s original public-health mission — preventing unintended pregnancies, lowering maternal risk, and delivering preventive reproductive care — would be damaged by the proposed shift. Jessica Marcella said the overhaul would ‘‘directly undermine the public health intent of our nation’s family planning program’’ and could exclude millions of people from services they have relied on for decades.
KFF Health News produced this reporting. KFF is an independent source of health policy research, polling, and journalism.