Global fertility in 204 countries and territories, 1950–2021, with forecasts to 2100: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

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Résumé

BACKGROUND: Accurate assessments of current and future fertility-including overall trends and changing population age structures across countries and regions-are essential to help plan for the profound social, economic, environmental, and geopolitical challenges that these changes will bring. Estimates and projections of fertility are necessary to inform policies involving resource and health-care needs, labour supply, education, gender equality, and family planning and support. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 produced up-to-date and comprehensive demographic assessments of key fertility indicators at global, regional, and national levels from 1950 to 2021 and forecast fertility metrics to 2100 based on a reference scenario and key policy-dependent alternative scenarios. METHODS: To estimate fertility indicators from 1950 to 2021, mixed-effects regression models and spatiotemporal Gaussian process regression were used to synthesise data from 8709 country-years of vital and sample registrations, 1455 surveys and censuses, and 150 other sources, and to generate age-specific fertility rates (ASFRs) for 5-year age groups from age 10 years to 54 years. ASFRs were summed across age groups to produce estimates of total fertility rate (TFR). Livebirths were calculated by multiplying ASFR and age-specific female population, then summing across ages 10-54 years. To forecast future fertility up to 2100, our Institute for Health Metrics and Evaluation (IHME) forecasting model was based on projections of completed cohort fertility at age 50 years (CCF50; the average number of children born over time to females from a specified birth cohort), which yields more stable and accurate measures of fertility than directly modelling TFR. CCF50 was modelled using an ensemble approach in which three sub-models (with two, three, and four covariates variously consisting of female educational attainment, contraceptive met need, population density in habitable areas, and under-5 mortality) were given equal weights, and analyses were conducted utilising the MR-BRT (meta-regression-Bayesian, regularised, trimmed) tool. To capture time-series trends in CCF50 not explained by these covariates, we used a first-order autoregressive model on the residual term. CCF50 as a proportion of each 5-year ASFR was predicted using a linear mixed-effects model with fixed-effects covariates (female educational attainment and contraceptive met need) and random intercepts for geographical regions. Projected TFRs were then computed for each calendar year as the sum of single-year ASFRs across age groups. The reference forecast is our estimate of the most likely fertility future given the model, past fertility, forecasts of covariates, and historical relationships between covariates and fertility. We additionally produced forecasts for multiple alternative scenarios in each location: the UN Sustainable Development Goal (SDG) for education is achieved by 2030; the contraceptive met need SDG is achieved by 2030; pro-natal policies are enacted to create supportive environments for those who give birth; and the previous three scenarios combined. Uncertainty from past data inputs and model estimation was propagated throughout analyses by taking 1000 draws for past and present fertility estimates and 500 draws for future forecasts from the estimated distribution for each metric, with 95% uncertainty intervals (UIs) given as the 2·5 and 97·5 percentiles of the draws. To evaluate the forecasting performance of our model and others, we computed skill values-a metric assessing gain in forecasting accuracy-by comparing predicted versus observed ASFRs from the past 15 years (2007-21). A positive skill metric indicates that the model being evaluated performs better than the baseline model (here, a simplified model holding 2007 values constant in the future), and a negative metric indicates that the evaluated model performs worse than baseline. FINDINGS: During the period from 1950 to 2021, global TFR more than halved, from 4·84 (95% UI 4·63-5·06) to 2·23 (2·09-2·38). Global annual livebirths peaked in 2016 at 142 million (95% UI 137-147), declining to 129 million (121-138) in 2021. Fertility rates declined in all countries and territories since 1950, with TFR remaining above 2·1-canonically considered replacement-level fertility-in 94 (46·1%) countries and territories in 2021. This included 44 of 46 countries in sub-Saharan Africa, which was the super-region with the largest share of livebirths in 2021 (29·2% [28·7-29·6]). 47 countries and territories in which lowest estimated fertility between 1950 and 2021 was below replacement experienced one or more subsequent years with higher fertility; only three of these locations rebounded above replacement levels. Future fertility rates were projected to continue to decline worldwide, reaching a global TFR of 1·83 (1·59-2·08) in 2050 and 1·59 (1·25-1·96) in 2100 under the reference scenario. The number of countries and territories with fertility rates remaining above replacement was forecast to be 49 (24·0%) in 2050 and only six (2·9%) in 2100, with three of these six countries included in the 2021 World Bank-defined low-income group, all located in the GBD super-region of sub-Saharan Africa. The proportion of livebirths occurring in sub-Saharan Africa was forecast to increase to more than half of the world's livebirths in 2100, to 41·3% (39·6-43·1) in 2050 and 54·3% (47·1-59·5) in 2100. The share of livebirths was projected to decline between 2021 and 2100 in most of the six other super-regions-decreasing, for example, in south Asia from 24·8% (23·7-25·8) in 2021 to 16·7% (14·3-19·1) in 2050 and 7·1% (4·4-10·1) in 2100-but was forecast to increase modestly in the north Africa and Middle East and high-income super-regions. Forecast estimates for the alternative combined scenario suggest that meeting SDG targets for education and contraceptive met need, as well as implementing pro-natal policies, would result in global TFRs of 1·65 (1·40-1·92) in 2050 and 1·62 (1·35-1·95) in 2100. The forecasting skill metric values for the IHME model were positive across all age groups, indicating that the model is better than the constant prediction. INTERPRETATION: Fertility is declining globally, with rates in more than half of all countries and territories in 2021 below replacement level. Trends since 2000 show considerable heterogeneity in the steepness of declines, and only a small number of countries experienced even a slight fertility rebound after their lowest observed rate, with none reaching replacement level. Additionally, the distribution of livebirths across the globe is shifting, with a greater proportion occurring in the lowest-income countries. Future fertility rates will continue to decline worldwide and will remain low even under successful implementation of pro-natal policies. These changes will have far-reaching economic and societal consequences due to ageing populations and declining workforces in higher-income countries, combined with an increasing share of livebirths among the already poorest regions of the world. FUNDING: Bill & Melinda Gates Foundation.

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La notice

Revue

The Lancet

Thématique

Global Maternal and Child Health

Domaine

Medicine

Établissements canadiens

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Organismes subventionnaires

National Human Genome Research InstituteRussian Academy of SciencesCanadian Institutes of Health ResearchHealth CanadaInjury Prevention Research CenterUniversity of California, IrvineDepartment of Epidemiology, Biostatistics and Occupational Health, McGill UniversityUniversity of California, San DiegoMedical Research CouncilRobert Koch InstitutBabcock UniversityWolkite UniversityWachemo UniversityLiverpool University Hospitals NHS Foundation TrustMadda Walabu UniversityIntas PharmaceuticalsHumanitas Research HospitalWestern Sydney UniversityHubei UniversityUniversity of NizwaUniwersytet Śląski w KatowicachI.M. Sechenov First Moscow State Medical UniversityH. Lundbeck A/SLorestan University of Medical SciencesMinistry of Science and Higher Education of the Russian FederationChettinad Academy of Research and EducationIndian Institute of Technology MandiGdański Uniwersytet MedycznyŚląski Uniwersytet Medyczny w KatowicachUniversity of Social Welfare and Rehabilitation SciencesUniversity of PeradeniyaUniversitas AirlanggaUniversidade Federal do Rio de JaneiroUniwersytet WrocławskiNational Institutes of HealthSoutheast UniversityNanjing UniversityNational Nutrition and Food Technology Research InstituteNational Cancer InstitutePeking UniversityUniversity of SulaimaniShaqra UniversityUniversidade Federal de Minas GeraisFondation BotnarUniversitatea din BucureștiSyracuse UniversityUniversidad Nacional Autónoma de MéxicoNational Research University Higher School of EconomicsUniversidade Federal de Juiz de ForaBill and Melinda Gates FoundationFederation University AustraliaUniversity of TabrizUnitatea Executiva pentru Finantarea Invatamantului Superior, a Cercetarii, Dezvoltarii si InovariiAristotle University of ThessalonikiKeio UniversityUniwersytet WarszawskiHokkaido UniversityBahir Dar UniversityUniversity of HailUniversitätsklinikum EssenUniversitat de BarcelonaUniversidade de LisboaUniversity of JordanCedars-Sinai Medical CenterKorea Institute for Advancement of TechnologyAkademiska SjukhusetUniversidad ICESITehran Heart CenterUniversitair Medisch Centrum GroningenTaibah UniversityAsia UniversityDivision of Human Resource DevelopmentNational Institute on AgingAustralian Academy of ScienceChinese University of Hong KongUniversity of South AfricaTaipei Medical UniversityHarvard Business SchoolUniversità degli Studi di GenovaDepartment of Global Health and Population, Harvard T.H. Chan School of Public HealthUniversity of the Western CapeAugusta UniversityUppsala UniversitetYonsei University College of MedicineChinese Center for Disease Control and PreventionTabriz University of Medical SciencesFakultet Medicinskih Nauka, Univerziteta U KragujevcuU.S. Environmental Protection AgencyShiraz University of Medical SciencesWarszawski Uniwersytet MedycznyKuopion Yliopistollinen SairaalaKhalifa University of Science, Technology and ResearchUniversity of WollongongAmerican Society of Transplant SurgeonsMultimedia UniversityKing Abdulaziz UniversityEuropean Regional Development FundUniversity of WindsorKarolinska InstitutetGovernment of Jiangsu ProvinceUniversidad Autónoma de MadridLinköpings UniversitetNational Research Foundation of KoreaUniversität RegensburgConselho Nacional de Desenvolvimento Científico e TecnológicoFundación Valle del LiliInyuvesi Yakwazulu-NataliUniversity of South CarolinaGazi ÜniversitesiMinistry of Trade, Industry and EnergyJapan Society for the Promotion of ScienceUniversity of MinnesotaAnhui Medical UniversityDirektorat Jenderal Pendidikan TinggiSungkyunkwan UniversityWellcome TrustKorea UniversityUniversity of LeedsNovo NordiskCorporación colombiana de investigación agropecuariaAjou UniversitySun Yat-sen UniversitySanofi GenzymeUniversity of PennsylvaniaTsinghua UniversityNational Taiwan Normal UniversityCairo UniversityPublic Health EnglandKyung Hee UniversityUniversity of ThessalyAXA Research FundUniversidad de AntioquiaUniversity of Oklahoma Health Sciences CenterMurdoch UniversityUniversiti Sains MalaysiaUniversity of CreteCurtin University of TechnologyMonash UniversityDeakin UniversityAteneo de Manila UniversityRijksuniversiteit GroningenMinistry of Education, Culture, Sports, Science and TechnologyDeutsche ForschungsgemeinschaftUniversity of DhakaUniversiteit StellenboschAmity UniversityDublin City UniversityUniversity of GalwayIndian Council of Agricultural ResearchMacquarie UniversityHellenic Foundation for Research and InnovationChulalongkorn UniversitySocial Science Research CouncilUniversity of GlasgowIndian Council of Medical ResearchUniversitas PadjadjaranMashhad University of Medical SciencesMassachusetts General HospitalUniversity College LondonNIH Clinical CenterUniversidad de ZaragozaUnited States Agency for International DevelopmentDepartment of Health and Social CareUniversità di CataniaNational Research FoundationUniversity of QueenslandNational Institute for Health and Care ResearchNorwegian Institute of Public HealthUK Research and InnovationRafsanjan University of Medical SciencesAmerican Heart AssociationUniversity of Engineering and Technology, LahorePrince Sattam bin Abdulaziz UniversityGovernment of CanadaKasturba Medical College, ManipalMcGill UniversityUniversity of KufaMinisterul Cercetării, Inovării şi DigitalizăriiUniversity of EmbuSeres TherapeuticsU.S. Department of Veterans AffairsUniversiti Tun Hussein Onn MalaysiaNational University of IrelandUniversity of North Carolina at Chapel HillEuropean CommissionGeorgetown UniversityAhmadu Bello UniversityDirectorate for Biological SciencesUniversity of Central FloridaKoch Institute for Integrative Cancer Research, Massachusetts Institute of TechnologyNankai UniversityIstituto di Ricerche Farmacologiche Mario Negri - IRCCSLondon South Bank UniversityUniversidade de São PauloQueen's UniversityGonabad University of Medical SciencesCharotar University of Science and TechnologyTomsk Polytechnic UniversityPublic Health Foundation of IndiaRajshahi UniversityKermanshah University of Medical SciencesUniversity of New South WalesEnvironmental Defense FundShahrekord University of Medical SciencesUniversity of NottinghamShiraz UniversityUniversity of the West of EnglandNorth South UniversityBiogenRadboud UniversiteitAksum UniversityShahid Beheshti University of Medical SciencesMinistry of EducationBirjand University of Medical SciencesNational Research CentreJazan UniversityLondon School of Economics and Political ScienceJimma UniversityYale UniversityLebanese American UniversityUniversiti Brunei DarussalamUniversity of BernUniverzita Karlova v PrazeUniwersytet Medyczny im. Karola Marcinkowskiego w PoznaniuAgios PharmaceuticalsUniversity of Technology SydneyTehran University of Medical Sciences and Health ServicesUniversity of OklahomaUniversity of TasmaniaAllerganWest Virginia UniversityAmgenAmarin CorporationNational Research, Development and Innovation OfficeUniversitas IndonesiaPatuakhali Science and Technology UniversityUniversity of MontanaJohns Hopkins UniversityICAR-Indian Veterinary Research InstituteYonsei UniversityBirzeit UniversityTeesside UniversitySRM Institute of Science and TechnologyUniversity of California, Los AngelesChina Medical UniversityMekelle UniversityItä-Suomen YliopistoKhulna UniversityAstraZenecaModernaCase Western Reserve UniversityHarvard UniversityIran University of Medical SciencesNorges Teknisk-Naturvitenskapelige UniversitetNemzeti Kutatási, Fejlesztési és Innovaciós AlapAmerican Association for the Study of Liver DiseasesMcMaster UniversityBerlin Institute of HealthSociety for Surgery of the Alimentary TractBrigham and Women's HospitalUniversity of South FloridaBundesministerium für GesundheitNanjing University of Chinese MedicineSouth African Medical Research CouncilMasarykova UniverzitaGilead SciencesAlexander von Humboldt-StiftungTribhuvan UniversityShahrekord UniversityCarolina Population Center, University of North Carolina at Chapel HillSanofiWorld Health OrganizationLa Trobe UniversityMenzies Institute for Medical ResearchBabol University of Medical SciencesUniversidad de ColimaCooperativa de Ensino Superior Politécnico e UniversitárioUniversity of Massachusetts BostonCentral South UniversityNational Science and Technology CouncilArabian Gulf UniversityHubei University of MedicineTrường Đại học Duy TânPomorski Uniwersytet Medyczny W SzczecinieUniversità degli Studi di Milano

Mots-clés

Burden of diseaseFertilityDiseaseDisease burdenGlobal healthDeveloping countryEnvironmental healthDevelopment economicsMedicineVirologyEconomic growthPublic healthEconomicsPopulationPathology

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