The Department of Health and Human Services (HHS) under the Trump administration is proposing significant changes to the Title X family planning program, reducing its traditional emphasis on contraception and expanding focus on fertility and other reproductive health issues. This shift comes as the U.S. birth rate continues to decline, with 3.6 million births recorded in 2025—a 1% decrease from the previous year and part of a longer-term 23% drop since 2007.
Title X, established in 1970, has been the only federal program dedicated to providing low-income women access to contraception, sexually transmitted infection screening, and reproductive health care. At its peak, Title X served over 5 million patients annually, with six in ten reporting it as their sole source of healthcare. The program has historically focused on preventing unintended pregnancies.
However, the new 67-page Notice of Funding Opportunity published in early April for fiscal year 2027 shifts the program’s priorities. The document mentions contraception only once, describing it as “overprescribed” and associated with “negative side effects,” and labels reliance on pharmaceutical and surgical treatments as excessive. Instead, it redirects attention to fertility, family formation, and reproductive health conditions such as polycystic ovary syndrome, endometriosis, low testosterone, and erectile dysfunction.
The revised funding announcement states that Title X will continue to help women “achieve healthy pregnancies” but omits explicit goals around preventing unintended pregnancies, a departure from the program’s historic purpose. Former senior Biden administration official Jessica Marcella called this a “wholesale redefinition of family planning,” criticizing it as an effort to use family planning policy for an “entirely different agenda.”
Experts question impact on birth rates
Demographers and fertility researchers assert that the ongoing decline in U.S. birth rates stems primarily from social and economic factors such as delayed childbearing linked to later life milestones like stable employment and marriage. Alison Gemmill, a UCLA demographer, noted that women are increasingly spacing births and delaying parenthood rather than foregoing having children altogether. Similarly, Philip Cohen, a University of Maryland sociology professor, said the average completed family size remains over two children per woman.
Economist Phillip Levine argued that reversing birth rate declines requires making childbearing more desirable rather than restricting contraception. Infertility rates in the U.S. have remained stable, even as birth rates drop, indicating that untreated reproductive health conditions are not a primary cause.
Controversy over reproductive health priorities
The administration’s changes have been positively received by some conservative advocates, such as Emma Waters of the Heritage Foundation, who applauded the focus on previously underserved reproductive health conditions and fertility education. Waters emphasized that conditions like endometriosis, which affects an estimated 5–10% of reproductive-age women and is linked to infertility in 30–50% of cases, deserve more attention.
However, medical experts note a contradiction in prioritizing diagnosis of conditions like endometriosis while de-emphasizing hormonal therapies, which remain a first-line treatment. Procedures known to improve fertility, such as laparoscopic surgery and IVF, are not covered under Title X.
Reproductive health advocates express concern that deemphasizing contraceptive services could reduce options for patients and shift funding toward providers less inclined to deliver comprehensive contraceptive care. Laura Lindberg, Rutgers School of Public Health, warned that such a move could impose more barriers to contraception access.
Why it matters
The U.S. faces one of the highest maternal mortality rates among wealthy nations, with 17.9 deaths per 100,000 live births as of 2024. Most pregnancy-related deaths are preventable, and access to effective contraception plays a critical role in reducing maternal health risks. The proposed changes to Title X may also affect the availability of family planning services to low-income individuals who rely on the program as their primary source of reproductive healthcare.
Since the Supreme Court’s 2022 Dobbs decision overturned federal abortion protections, reproductive health policy debates have intensified. The redefinition of Title X amid ongoing birth rate challenges underscores complex intersections between public health, politics, and individual reproductive rights.
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