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조장: 엄서윤
자료 제작: 신은파
발표: 이우원
자료 조사: 신은파, 엄서윤, 이우원

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조장 : 김재훈
자료조사 :  조하람 오서진 이시윤
제작 : 엄태후
발표 : 조하람

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1. 1Hong Kong University of Science and Technology, Kowloon, Hong Kong SAR, People's Republic of China

2. 2Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates

3. 3Population Research Institute, Väestöliitto, Family Federation of Finland, Helsinki, Finland

4. 4Vienna Institute of Demography, Wittgenstein Centre for Demography and Global Human Capital (IIASA, OeAW, University of Vienna), Vienna, Austria

Correspondence to: S Gietel-Basten stuart.gietelbasten{at}ku.ac.ae

Stuart Gietel-Basten, Anna Rotkirch, and Tomáš Sobotka argue that policies responding to population decline and ageing should enable reproductive choice and maximise the potential of all citizens

The news that birth rates hit record low levels in many countries in Europe, Asia, and the Americas in the past decade was met with some alarm globally. More than half of the world's population lives in countries with a total fertility rate below two children per woman. The rate is below 1.5 in 46 countries ( fig 1), and ranges from 1.3 to 1.8 in many middle income countries such as Brazil, Iran, China, Turkey, and India. 1 Countries that, until recently, had fertility rates around 1.8-2.0 such as France, US, UK, and those in the Nordic region also now have declining birth rates. In South Korea the rate fell to 0.81 children per woman in 2021, an unprecedented low for any country in peacetime. Adversities and anxieties linked to the covid-19 pandemic, Russia's invasion of Ukraine, and climate change may further contribute to fertility declines. 2

As a primary engine of population ageing and stagnation, low birth rates are often viewed as a threat to welfare systems, healthcare, and the economy. The concern is that lower birth rates imply that, in several decades, there will be fewer economically active people to fund health and welfare systems as well as increasing demands on these systems. Rather than reforming such stressed systems through, for example, altering the pension age or raising tax (which may be politically unpopular), many governments have sought to find a demographic solution by pursuing top-down, target driven policies to encourage childbearing. Such policy responses have questionable justifications, limited effect on fertility, and potentially harmful effects on sexual and reproductive health, human rights, and gender equality.

People in countries with low fertility rates desire, on average, to have more children than they do. 3 Adopting a person centred, inclusive, rights based, and gender sensitive approach to fertility, following principles set out at the 1994 International Conference of Population and Development (ICPD; box 1), 6 is more likely to deliver a sustainable response to low fertility.

1994 UN International Conference of Population and Development

Big changes in health and longevity drove an increase in global population from 2.5 billion in 1950 to 5.3 billion by 1990. 1 This perceived unrestrained demographic growth resulted in fears of resource scarcity, environmental collapse, and overcrowding, 4 leading stakeholders to advocate reducing fertility, sometimes through coercive and draconian measures such as China's one child policy. 5

The 1994 International Conference of Population and Development (ICPD) affirmed that sustainable demographic change was key to shaping macroeconomic prospects. 6 However, its programme of action marked a paradigm shift by focusing on reproductive health, gender equality, and individual wellbeing rather than governmental needs or demographic targets. 7

Implementation of the ICPD programme has not been without controversy. The voluntary family planning it espoused has been linked to an overarching narrative of fertility reduction and presented as way to resolve development problems. 8 There was also much disagreement concerning funding, integration, and the right to induced abortion and its role in reproductive health services. 9 10 11
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Still, the core principles remain valid: individuals should be empowered to realise their reproductive goals on the basis of human rights, dignity, and gender equity within the context of sexual and reproductive health and rights. 12

Target driven pronatalism risks health

Almost all countries with a total fertility rate below 1.5 have policies in place to raise fertility ( fig 2). 13 Many governments have launched policies intended as a quick, politically expedient demographic fix to the challenges of population ageing and stagnation. 14 Rather than follow ICPD principles, countries such as Belarus, Japan, Republic of Korea, Hungary, Turkey, Poland, and Russia have adopted pronatalist policies that use narrowly oriented interventions to encourage or pressure women to have more children to reach a target fertility rate (usually around two children) and population size. 15 Although financial support for new parents is common in welfare systems around the world, 16 in target driven pronatalism payments are intended to encourage marriage and larger families. Some examples include the "baby bonuses" in Singapore, which pay out more for couples with three or more children; interest-free loans to prospective parents in Hungary that do not have to be repaid if a couple has at least three children within five years; and the "maternity capital" in Russia, a one-off benefit that has been provided to mothers of second or third children since 2007. 17

Of equal importance to the actual policies is the rhetoric surrounding them, which often combines the "mission" to raise birth rates with a promotion of conservative family values, where women have a duty and responsibility to bear children and thus secure the future of the nation. 16 By promoting the childrearing role of mothers while ignoring men's contribution, top-down pronatalist policies and discourses tend to reimpose conservative family and gender roles and reverse progress on gender equity and rights for sexual and gender minorities. 18 19 Access to abortion, contraception, and sexual education is often curbed. In Poland, for example, restrictions on abortion were further tightened in January 2021, shortly before the government presented its demographic strategy, which aims to "get out of the trap of low fertility rate." 20 In Iran, as a part of the push to increase fertility, a law enacted in November 2021 curbs access to abortion, eliminates free provision of contraception, prohibits voluntary sterilisation, restricts prenatal screening, and broadens surveillance on access to family planning services. 21 In China, the latest round of policies designed to achieve "an appropriate childbearing level" includes provisions to "reduce abortions that are not medically necessary." 22 Certain groups (eg, unmarried parents, sexual and gender minorities, and couples without children) can be stigmatised and penalised.

Target driven policies are often embedded within an authoritarian and ethnonationalist propagandist discourse. The "general population policies" announced by the supreme leader of Iran, Ayatollah Khamenei, in 2014 called for "promoting and establishing an Islamic-Iranian lifestyle and confronting the negative aspects of the western lifestyle." 23 In Turkey, President Erdoğan has declared that all families should have at least three children. 24 Russia's president Vladimir Putin reintroduced the Soviet era medal for "mother heroines" with 10 or more children in 2022, 25 and deputies of the Russian State Duma introduced a bill banning information promoting the "foreign child-free ideology." 26

Ethnonationalism becomes explicit in discussions of differential fertility rates by ethnic groups, as exemplified in the discourses about perceived high fertility among the Roma ethnic group in central and eastern Europe, including Bulgaria. 27 Although immigration can slow the pace of population ageing and counter fertility decline, it contradicts ethnonationalist goals. Hungary's prime minister, Viktor Orbán, has emphasised that government population policies aimed at increasing the number of Hungarian children are a fight against "a suicidal attempt to replace the lack of European, Christian children with adults from other civilisations-migrants." 28

Miscalculated approach

Target based pronatalist policies often rest on a questionable assessment of demographic measures and change and are thus unlikely to achieve their objectives. Firstly, pronatalist policies often affect the timing and spacing of births rather than the total number born to a particular cohort of women-for example, the short lived baby booms in Russia in the 1980s and 2000s following more generous family benefits. 29 Restrictions to abortion have historically led to a rise in illegal abortions and worse health for women and children, without long term fertility gains. 30 Secondly, population decline in many low fertility settings, especially in central, southeastern, and eastern Europe, has been exacerbated by emigration brought about through poor employment opportunities. 31 Simply put, if babies that are born because of pronatalist policy move away to work elsewhere at the earliest opportunity, the net population impact is zero.

Reproductive empowerment

The international and moral consensus against target driven birth policies was settled at the ICPD ( box 1). 6 It affirmed a health and human rights approach that prioritises empowering individuals to realise their reproductive goals as the mechanism by which to influence fertility rates. The ICPD principles, which aim to reduce the gap between desired and actual fertility, were successful in lowering high birth rates and can now also help governments to avoid very low birth rates. This consensus has been restated in various follow-on summits, such as ICPD+25 Nairobi 2019, and with target 3.7 of the sustainable development goals calling for universal access to sexual and reproductive healthcare services, and the integration of reproductive health into national strategies and programmes.

In countries with low fertility rates, many people aspire to have more children than they end up with. 3 The gap between fertility aspirations and actual family size-combined, in some countries, with high rates of emigration-are often symptoms of societal and economic dysfunction, including discrimination, imbalanced labour market, gender inequality, an unsustainably work oriented culture, and inadequate social support for families and young adults. 19 Countries with low fertility rates need comprehensive policies to support the healthy growth and development of families. 32 These include, for example, high quality and affordable childcare provision, flexible and well paid parental leave, work flexibility, job protection for parents, and policies supporting both partners' involvement in child rearing.

Some middle and higher income countries, including Estonia, Moldova, and Uruguay, have recently adopted such inclusive family policies while also broadening access to health and social policies. 33 34 Financial transfers provided in many higher income countries (such as monthly child allowances, paid maternity and parental leave schemes, subsidised early childhood education, and dedicated marriage or housing loans) also offset some direct costs of childbearing and reduce poverty among families with children. 35

Gender sensitive family policies can offset some of the indirect costs of family formation, which are disproportionately shouldered by women, while also addressing men's wishes and challenges related to childbearing. Currently, access to sexual and reproductive health services is highly unequal both between and within countries. 36 37 Single women and gender and sexual minorities are often unable to access fertility treatment. 38 39 Demand for assisted reproductive technology and (in)fertility counselling is growing-not least because of rising parental ages and involuntary childlessness. 40 41

Historically, generous family policies in France, Germany, and Estonia, for instance, have been partly linked with stated pronatalist goals. However, family friendly policies in these countries today are aligned with human and reproductive rights and support families to maximise social and economic wellbeing rather than arbitrary goals of the state. Hence, governments concerned about demographic trends should give more priority to initiatives to prevent infertility and involuntary childlessness and raise fertility awareness and reproductive empowerment. Young adults should be provided with the skills and services needed for planning their family life, just as they plan their work careers. Such educational and medical services need to be sensitive to the needs and wishes of different families, without stigmatising child-free lifestyles. These policies should be built on a strong grounding of sexual and reproductive health and rights and enhance family and children's wellbeing.

Beyond birth rates

Even if slightly higher birth rates can be achieved, major societal changes need to be tackled now, irrespective of future birth trends. Urgent reform of health and welfare systems is required to meet the demands of an ageing population. 42 Other dimensions of population change, especially education and health, contribute to increased wellbeing and productivity and could offset many of the challenges linked with population ageing. 43

Countries with smaller, older populations need to realise the full social and economic potential of all citizens, including migrants and their families. This involves continued investment in maintaining wellbeing and good health from infancy into old age, which is lagging in many countries, including the UK. 44 Countries with recent target driven policies such as Iran and Turkey often have much potential to maximise their existing human capital, not least through lowering child poverty and youth unemployment and increasing female participation in the labour force. 45

Focusing on the wellbeing of children and their families and caregivers should be the first priority of every ageing society. Countries in the early stages of population ageing can also learn lessons from demographically older countries and create sustainable institutions that are resilient to continued demographic changes. This requires working with civil society, the private sector, and families to adopt holistic policies for healthy and active ageing, labour market and pension reform, family friendliness, and better immigration as well as promoting reproductive rights and empowerment. Securing political support to bring about such reforms is not easy, as shown by the slow progress since the ICPD programme of action. However, we must learn from history and push back against attempts to fix the problem by telling women how many babies they should have.

Low birth rates, linked to population ageing and stagnation, are a source of concern in many countries of the world

Many governments have introduced target driven policies to spur the birth rate

These policies often negatively affect gender equity, reproductive health, and sexual rights and are unlikely to be successful in their stated aims

Other governments have focused on family friendly policies and increasing the wellbeing of all children

Governments, civil society, and other stakeholders should concentrate on tackling the key institutional challenges associated with population ageing, enabling all citizens to reach their full potential, and supporting reproductive empowerment

Key messages

Contributors and sources: SG-B, TS, and AR are social science researchers who explore family changes around the world through a multidisciplinary, comparative demographic lens. All three authors have worked extensively on applied family policy, working with governments, civil society, and other stakeholders. All contributed equally to the conceptualisation, development, and writing of the article.

Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.

Provenance and peer review: Commissioned; externally peer reviewed.

Publisher's note: Published maps are provided without any warranty of any kind, either express or implied. BMJ remains neutral with regard to jurisdictional claims in published maps.

Footnotes

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Changing the perspective on low birth rates: why simplistic solutions won't work

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Stuart Gietel-Basten , Anna Rotkirch , and Tomáš Sobotka argue that policies responding to population decline and ageing should enable reproductive choice and maximise the potential of all citizens The news that birth rates hit record low levels in many countries in Europe, Asia, and the Americas in the past decade was met with some alarm globally.

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이란에서는 출산율을 높이기 위한 노력

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이란에서는 출산율을 높이기 위한 노력의 일환으로 2021년 11월에 제정된 법률을 통해 낙태에 대한 접근을 억제하고, 무료 피임법 제공을 철폐하고, 자발적 불임수술을 금지하고, 산전 검사를 제한하고, 가족 계획 서비스 접근에 대한 감시를 확대했습니다. 중국에서는 “적절한 출산 수준”을 달성하기 위해 고안된 최신 정책에 “의학적으로 필요하지 않은 낙태를 줄이는” 조항이 포함되어 있습니다.

일본, 대한민국, 헝가리, 터키, 폴란드, 러시아와 같은 국가에서는 ICPD 원칙을 따르기보다는 여성이 목표 출산율에 도달하기위해 더 많은 아이를 갖도록 장려하거나 압력을 가하기 위해 협소한 개입을 사용하는 산전주의 정책을 채택했습니다

몇 가지 예로는 3명 이상의 자녀를 둔 부부에게 더 많은 금액을 지급하는 싱가포르의 "베이비 보너스"가 있습니다. 부부가 5년이내에 최소 3명의 자녀를 낳는 경우 상환할 필요가 없는 헝가리의 예비 부모를 위한 무이자 대출; 러시아의 '모성자본'은 2007년부터 둘째, 셋째 자녀의 엄마들에게 일회성 혜택으로 제공되고 있다. 러시아 대통령 블라디미르 푸틴은 2022년에 10명 이상의 자녀를 둔 '어머니 영웅'에게 소련 시대 메달을 다시 도입했다

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다른 나라의 저출산 문제 해결 방안 (2)

# data[].attributes.subject
다른 나라의 저출산 문제 해결 방안 (2)

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헝가리 - 1. 4명 이상의 아이를 가진 여성일 경우

평생 소득세 면제

2. 5년 이내 1명 이상의 자녀 출산 시 대출이자 면제

3. 2명 이상 자녀 출산 시 대출액의 1/3 탕감

4. 3명 이상의 자녀 출산 시 대출액 전체 탕감

스웨덴 - 남성의 육아휴직을 여성과 동일안 90일로 확대, 보육시설 확대, 부모 모두 육아휴직 사용시 추가수당 지급

독일 - 아빠가 두 달간 육아휴직을 할 경우, 두 달 더 휴직 가능, 이민자 적극 수용, 근로소득 지원, 보육시설 확층

# data[].attributes.headline
저출산과 고령 사회가 사회, 경제 전반에 미치는 영향

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저출산과 고령 사회가 사회, 경제 전반에 미치는 영향

# data[].attributes.body
1. 평균 근로 연령 상승
2. 지출, 소비, 투자 위축 등으로 국가 경쟁력 약화
3. 생산 가능 인구(15세~64세)의 감소
4. 경제 성장 둔화에 따른 수입 감소

-> 저출산과 고령화 현상은 경제 성장을 둔화시키고, 사회 전반에 악영향을 미친다.

# data[].attributes.body
조장: 김동우
발표: 정이환
제작: 성소현
조사: 김동우 김소형 김예은 성소현 윤진 정이환

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우리나라 저출산, 고령화 원인

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우리나라 저출산, 고령화 원인

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<저출산원인>

1. 경제적 원인: 높은 부동산 가격, 교육비 및 점증하는 경제적 불안 등 젊음 층이 가족을 꾸리지 못함.

2.사회적 원인: 아직 남성이 일하고 여성이 가사를 담당하는 사회이다. 한국남성이 가사에 참여를 하고싶어도, 한국의 노동문화가 이를 허락하지 않는다. 지나치게 긴 노동시간, 육아휴직제도를 활용하기 어려운 노동환경이 저출산 문제의 원인이다.

<고령화 원인>
출산률 저하와 사망률 저하. 의료기술이 발전하면서, 평균수명이 길어짐.

# data[].attributes.headline
저출산과 고령사회가 개인 및 가족에게 미치는 영향

# data[].attributes.subject
저출산과 고령사회가 개인 및 가족에게 미치는 영향

# data[].attributes.body
1. 실업이 증가해 고용이 불안해짐 -> 실업증가 악순환
2. 노인부양의 부담이 증가함  -> 세대간의 갈등도 발생
3. 결혼 및 출산을 포기-> 저출산 악순환
4. 경제 악화로 수입이 감소
5. 국가세입이 감소해 복지혜택이 감소

# data[].attributes.body
조장:서서윤
발표:이호주
제작:오성훈
자료조사:이호주,이지훈,서서윤,허지윤,이예준 ,오성훈

# data[].attributes.headline
-저출산/고령 사회가 미치는 영향

# data[].attributes.subject
-저출산/고령 사회가 미치는 영향

# data[].attributes.body
(1)개인적 차원
건강 악화, 가족으로부터의 수발 서비스 수급, 노후 생활의 경제적 문제, 여가선용과 역할 없는 수행, 배우자 상실과 고독, 소외의 영향
(2)가족 차원
가족 수발 짜와 수발 부담과 갈등, 의료비 부담 증가, 주거와 가족제도의 변화, 가족 외적 서비스 이용 증가, 배우자 상실과 고독, 소외
(3)사회적 차원
노인 단독세대의 증가, 노동자의 고령화와 저출산의 영향으로 노동인력 부족, 경제 성장률 저하, 공적연금 보험료 부담의 증가, 절대적 상대적 빈곤 노인에 대한 사회적 비용 부담 증가 (국가 재정 증가), 노인의 다양한 서비스, 가족 구조와 생활 양식 변화(전통적 대 가족 구조->핵 가족 또는 독거 노인 가구)
(4)정치적 영향
노인 인구 증가로 정치 성향 변화와 노년층을 위한 정책 수와 증가

# data[].attributes.body
조장 : 이수영
자료조사 : 정승우, 여준화
자료제작 : 유현서
발표 : 이현준

# data[].attributes.body
조장: 장현지
발표: 박수빈
제작: 박시현
자료조사: 박현빈, 안서진

# data[].attributes.headline
저출산,고령 사회가 미치는 영향

# data[].attributes.subject
저출산,고령 사회가 미치는 영향

# data[].attributes.body
1.개인적 차원
1) 실업 증가하며 고용불안
2)노인을 부양해야 하는 부담 증가
3)결혼 및 출산이 연기되거나 포기
4)경제 악화로 수입 감소
5)국가 단체의 수입 감소로 인한 복지 혜택 감소
2.사회적 차원
1)평균 근로 연령 상승
2)지출,소비,튜자 위축 등 국가 경쟁력 약화
3)생산이 가능 인구(15세~64세) 감소
4) 경제성장 둔화에 따른 정부 또는 지방자치단체의 수입 감소
5)노인 인구 증가로 젱치 성향 변화와 노년층을 위한 정책 수 증가
6)노인의 다양한 서비스,가족 구조와 생활 양식 변화

# data[].attributes.headline
우리나라 저출산•고령 사회의 원인 (2)

# data[].attributes.subject
우리나라 저출산•고령 사회의 원인 (2)

# data[].attributes.body
[저출산의 원인]
(1) 경제적 원인 : 집값과 물가 상승에 비해 수입은 많이 오르지 않아서 경제적으로 버티기 힘듦. 받고 있는 월급으로 결혼과 출산을 하는 것에 어려움이 있음.
(2) 문화적 원인 : 일-가정 양립이 어려움. 현재까지 남아있는 대한민국의 가부장적인 문화가 비혼주의자, 딩크족을 증가시킴.

[고령 사회의 원인]
(1) 평균 수명 증가 : 의료기술의 발전, 보건상태의 개선 등이 평균 수명 증가에 기여함.
(2) 출산율 감소 : 여성의 사회 참여 증가, 교육기회의 확대 등으로 인해 출산율이 떨어짐.
(3) 사회적 변화 : 가족 구조의 변화, 가족 단위의 축소, 독거 노인의 증가 등이 고령화를 가속화함.

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프랑스 - 경제사정에 관계 없이 2명이상 키울 시 무조건 가족수당을 시급하고, 출산보너스 및 신생아 환영수당을 지급한다.
영국 - 한자녀 이상의 모든 가정에 아동수당을 지급한다.
중국 - 다자녀 가구에 공공주택 아파트를 제공하고, 3세 미만의 아이를 둔 다자녀 부부에게는 기존 세제 혜택 외에도 세금 감면 혜택도 제공하기 시작했다. 또함 자녀가 있는 직원들은 탄력근문는 물론, 재택근무도 할 수 있게
지원하겠다고 했다.
스웨덴 - 1995년 세계 최초로 남성 육아휴직제를 도입한 데 이어 2016년엔 남성의무 육아휴직기간을 여성과 동일한 90일로 확대했다. 또 부모가 모두 육아휴직을 사용한 경우 추가수당을 지급하고 있다. 육아휴직 중인 여성에게 휴직 전 급여의 80%를 지급하고, 480일간 육아휴직 중 부부 한쪽이 반드시 60일을 사용토록 의무화해 남성들의 가사 분담률을 높이고 있다.

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