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\title{COVID-19 Pandemic and Sub-Replacement Fertility}



\author[1]{shahul ebrahim}%
\author[2]{yusuf ahmed}%
\author[3]{Rubina Imtiaz}%
\affil[1]{University of Sciences Techniques and Technologies of Bamako}%
\affil[2]{University of Zambia School of Medicine}%
\affil[3]{Taskforce for global health}%


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  \date{June 14, 2024}


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As the COVID-19 pandemic continues to surge, the conjectured linkages
between pandemics, fertility, and child health observed during the great
depression of 1957 in the USA and the influenza pandemic of 1918 in the
USA and Japan become highly relevant.\textsuperscript{1,2} From 1900s
through 1970s, along with the economic and epidemiologic transitions,
standardized child mortality from infectious diseases decreased by 90\%
overall, birth defects remained the leading cause of ill health, and
fertility rates declined. Pre-COVID-19 fertility projections for 2020
indicate that 66 countries of the countries currently experience
sub-replacement fertility (Figure), below the global average fertility
of 2.3 and the sub-replacement fertility level of
2.1.\textsuperscript{3} The fertility rate of 2.1 as the sub-replacement
level is derived from the assumption that, in a community, two children
per women are required to replace parents and 0.1 child to make up for
child mortality prior to becoming an adult. Fertility rate at or below
1.7 is considered severe (45 countries) because interventions (excluding
immigration of populations with high fertility) are unlikely to achieve
the 2.1 replacement target.

Impact of Pandemics on Fertility and Child Health

Pandemics can adversely affect both fertility and child
survival.\textsuperscript{1,2} The mechanisms that linked pandemics with
subsequent depressed fertility during the past pandemics include a
combination of reduced conceptions and embryonic losses during the first
month of pregnancy, individual level stress from pandemics and
pandemic-related mortality, short-run instability from environmental
shocks and economic volatility leading to decreased investment in the
population size of future generations.

Child development may be affected by community mitigation activities
including home quarantine, social distancing, and closing of economic
and travel activities, reduced access to child day care, interruption in
schooling and nutrition opportunities for many children. These effects
are amplified if the child is cared for by single parents or parents in
employment categories such as the service sector that is immediately
affected by mitigation strategies. We lack contemporary studies on the
impact of these outcomes. Social and family structures during historic
events differed greatly from that of today. In countries that experience
sub replacement fertility, population of childbearing age is
characterized by single households, increased mean age of women at first
birth (higher order births), nuclear families, increased participation
of women in the workforce, high percentage of dissolved family unions,
and inadequate unemployment benefits and social support systems to
support families.\textsuperscript{4,}

The evolution of the COVID-19 pandemic occurred in a condensed timeframe
and SARS-CoV-2 related embryonic loss has not been reported. With the
addition of COVID-19 related childhood multisystem inflammatory syndrome
to birth defects (current burden in developed countries, 40 to 55 per
1000 live births\textsuperscript{5}), the overall child morbidity will
increase. The spread of COVID-19 and mortality has been significant
among many of the countries that experience sub replacement fertility
and the incidence is increasing in the younger ages as currently
observed in the U.S. COVID -19. Mitigation efforts can adversely impact
child survival and fertility decisions due to changes in ratio of
workers to dependents, changes in the labor supply of working-age adults
over time, and changes in the average level of schooling.

Given that the countries that face sub-replacement fertility are also
the leading drivers of innovation and productivity globally
(figure)\textsuperscript{3,6}, further stress on fertility in these
countries will no doubt impact their economic security and contribution
to global development in the next two decades.

Actions to Improve Fertility and Improve Child Well Being

Countries in sub-replacement fertility status have explored social,
economic, and policy interventions to reverse the trend. They include
policies to balance work and family obligations, financial incentives
(fertility boosters, monthly childcare benefit linked to family size),
speed premium (financial incentives for delivery of second child within
a given time frame), free childcare, and housing
subsidies.\textsuperscript{7} Immigration played a major role in
sustaining fertility rates at replaceable levels in the USA. The~easing
of the one-child policy in China in 2016 increased the number of births
by 8\% over 2015. Given that fertility change is a long-term cohort
effect, influenced by various exogenous factors, select measures are
unlikely to achieve long-term benefits unless a complete set of
supportive interventions across the lifespan of the parents and child
are implemented in concert.

Unlike during historic events, COVID-19's impact on fertility should be
of concern for relevant countries. Efforts to aid population growth and
health outcome of children born today are needed in high-risk countries
so that many more women achieve healthy reproductive goals and their
children achieve optimal health. We highlight 7 actions points below.

\begin{itemize}
\tightlist
\item
  Strengthen and expand newborn screening programs to identify and
  provide early intervention for birth defects and assure special care
  the affected children.
\item
  Educate the public about steps that fathers and communities can take
  to support women to achieve healthy reproductive outcomes.
\item
  At the policy level, use COVID-19 as an opportunity to advocate,
  develop and integrate to social programs and labor sector a
  comprehensive list of supportive interventions across the life span of
  the parent-child dyad.
\item
  Integrate pre-conception care concepts to clinical practice to enable
  women of childbearing age to achieve optimal mental and physical
  health during COVID-19 and ensure a healthy balanced diet, including
  folic acid fortification or supplementation, correcting iodine
  deficiencies and avoiding teratogens such as alcohol and tobacco.
\item
  Optimize maternal health through control of chronic diseases that
  increases a woman's risk for both COVID-19 and adverse child outcomes.
\item
  Among intrauterine and child survivors of COVID-19, monitor potential
  long term impact of COVID-19 throughout the child's growth and
  development period.
\item
  Assure the continuity and comprehensiveness of high-quality child
  education and social interaction opportunities through innovative
  virtual programs when in-person education is unavailable.
\end{itemize}

With the aging of populations and the interconnectedness of our
economies, COVID-19's potential impact in countries that are already
facing sub-replacement fertility should receive due consideration in
programs aimed at improving the health of the mother and child. Doing so
would be a necessity not only form a national security perspective, but
from a long-term economic prosperity, not just for those countries at
high risk, but for all countries.

Summary (optional)

Pandemics can adversely affect both fertility and child survival. The
pathways include adverse biological outcomes (those caused as a direct
result of infections on fetus, newborn, or children), ecological impact
on fertility (due to indirect causes that leads to postponement or lack
of reproduction), and as a result of unintended consequences of
community mitigation on growth and development of
children\textsuperscript{1-4} Globally 66 countries, mostly those the
global innovation hubs with the highest per capita GDP, already have
fertility rates below 2.1, of which 45 are at or below the irreversible
rate of 1.7. As COVID-19 incidence is increasing in the younger ages,
population growth plans to avert further deterioration of fertility and
assure optimal health of children are needed in countries with
sub-replacement fertility.

Figure. Countries facing sub-replacement fertility (TFR\textless{}2.1),
their global ranking by per-capita gross domestic product (GDP) and
innovation index\textsuperscript{1,6 .} Fertility rates below 1.8 marked
by vertical blue line are considered irreversible

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References

\begin{enumerate}
\tightlist
\item
  Schneider, D. The Great Recession, Fertility, and Uncertainty:
  Evidence From the United States. Fam Relat 2015, 77: 1144-1156.
  doi:\emph{10.1111/jomf.12212}
\item
  Chandra S, Yu YL. The 1918 influenza pandemic and subsequent birth
  deficit in Japan. Demographic Research. 2015 Jul 1;33:313-26.
\item
  The World Factbook. Country comparison: total fertility rate.
  https://www.cia.gov/library/publications/the-world-factbook/rankorder/2127rank.html.
  Accessed May 25, 2020.
\item
  Brinton MC, Bueno X, Ol\selectlanguage{ngerman}áh L, Hellum M. Postindustrial fertility
  ideals, intentions, and gender inequality: A comparative qualitative
  analysis. Population and development review. 2018 Jun;44(2):281-309.
\item
  March of Dimes Birth Defects Foundation. Global report on birth
  defects. White Plains, New York 2006.
  https://www.marchofdimes.org/global-report-on-birth-defects-the-hidden-toll-of-dying-and-disabled-children-full-report.pdf
\item
  Global Innovation Index 2020.
  https://www.globalinnovationindex.org/Home. Cornell University, INSEAD
  WIPO. Accessed June 15, 2020
\item
  United Nations. Population Division. Government policies to raise or
  lower the fertility level.
  https://www.un.org/en/development/desa/population/publications/pdf/popfacts/PopFacts\_2017-10.pdf.
  accessed May 15, 2020.
\end{enumerate}

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