State-specific fertility rate changes across the USA following the first two waves of COVID-19

Abstract

Study question: How did the first two coronavirus disease 2019 (COVID-19) waves affect fertility rates in the USA?

Summary answer: States differed widely in how their fertility rates changed following the COVID-19 outbreak and these changes were influenced more by state-level economic, racial, political, and social factors than by COVID-19 wave severity.

What is known already: The outbreak of the COVID-19 pandemic contributed to already declining fertility rates in the USA, but not equally across states. Identifying drivers of differential changes in fertility rates can help explain variations in demographic shifts across states in the USA and motivate policies that support families in general, not only during crises.

Study design, size, duration: This is an ecological study using state-level data from 50 US states and the District of Columbia (n = 51). The study period extends from 2020 to 2021 with historical data from 2016 to 2019. We identified Wave 1 as the first apex for each state after February 2020 and Wave 2 as the second apex, during Fall/Winter 2020-2021.

Participants/materials, setting, methods: State-level COVID-19 wave severity, defined as case acceleration during each 3-month COVID-19 wave (cases/100 000 population/month), was derived from 7-day weekly moving average COVID-19 case rates from the US Centers for Disease Control and Prevention (CDC). State-level fertility rate changes (change in average monthly fertility rate/100 000 women of reproductive age (WRA)/year) were derived from the CDC Bureau of Vital Statistics and from 2020 US Census and University of Virginia 2021 population estimates 9 months after each COVID-19 wave. We performed univariate analyses to describe national and state-level fertility rate changes following each wave, and simple and multivariable linear regression analyses to assess the relation of COVID-19 wave severity and other state-level characteristics with fertility rate changes.

Main results and the role of chance: Nationwide, fertility dropped by 17.5 births/month/100 000 WRA/year following Wave 1 and 9.2 births/month/100 000 WRA/year following Wave 2. The declines following Wave 1 were largest among majority-Democrat, more non-White states where people practiced greater social distancing. Greater COVID-19 wave severity was associated with steeper fertility rate decline post-Wave 1 in simple regression, but the association was attenuated when adjusted for other covariates. Adjusting for the economic impact of the pandemic (hypothesized mediator) also attenuated the effect. There was no relation between COVID-19 wave severity and fertility rate change following Wave 2.

Limitations, reasons for caution: Our study harnesses state-level data so individual-level conclusions cannot be inferred. There may be residual confounding in our multivariable regression and we were underpowered to detect some effects.

Wider implications of the findings: The COVID-19 pandemic initially impacted the national fertility rate but, overall, the fertility rate rebounded to the pre-pandemic level following Wave 2. Consistent with prior literature, COVID-19 wave severity did not appear to predict fertility rate change. Economic, racial, political, and social factors influenced state-specific fertility rates during the pandemic more than the severity of the outbreak alone. Future studies in other countries should also consider whether these factors account for internal heterogeneity when examining the impact of the COVID-19 pandemic and other crises on fertility.

Study funding/competing interest(s): L.G.K. received funding from the National Institute of Environmental Health Sciences (R00ES030403), M.C. from the National Science Foundation Graduate Research Fellowship Program (20-A0-00-1005789), and M.L. and E.S. from the National Institute of Environmental Health Sciences (R01ES032808). None of the authors have competing interests.

Trial registration number: N/A.

Keywords: COVID-19; US state analysis; birth rates; coronavirus disease 2019; ecological study; fertility; fertility trends; pandemic; severe acute respiratory syndrome coronavirus 2; social determinants.

Figure 1.

Calculation of annual change in average monthly fertility rate for New York and Rhode Island following COVID-19 waves. Each panel represents the fertility rate (average monthly births/100 000 women of reproductive age) in the 9 months following each coronavirus disease 2019 (COVID-19) wave compared to the fertility rate in the same months in previous years (1 year prior for Wave 1, 2 years prior for Wave 2). The dotted lines show the mean fertility rate for each period. The vertical black lines indicate the annual (Wave 1) or biannual (Wave 2) average monthly fertility rate change.

Figure 2.

State-specific annual fertility rate change for pre-pandemic period, post-Wave 1 and post-Wave 2 for each US state. The top map of the USA shows state-specific annual change in fertility rate (average monthly births/100 000 women of reproductive age) pre-coronavirus disease 2019 (COVID) (averaged from 2016 to 2019). The middle and bottom map shows the state-specific annual change in fertility rate following Wave 1 and Wave 2, respectively.

Figure 3.

Annual fertility rate change in the USA in relation to social distancing index and political leaning following Wave 1. Following Wave 1, fertility rate change is correlated with Social Distancing Index (x-axis) and political leaning (red: Republican, blue; Democrat). Social Distancing Index is a scale from 0 to 100, with higher values indicating greater levels of social distancing. Political leaning is the percentage of the state that voted Republican in the 2020 election. The size of the point indicates the number of women of reproductive age in that state during 2020.