The Pronatalist Movement Cares About Babies. Does It Care About Moms?

Why I'm Not Convinced

“There is no such thing as a baby…there is a baby and someone.” -D.W. Winnicott

“In our current system of care, the baby is the candy and the mother is the wrapper. Once the candy is out of the wrapper, the wrapper is cast aside.” -Alison Stuebe

A Scary Moment Last Week

A few days ago, I was in clinic when a 39-week pregnant woman who I had been seeing regularly—pregnant with her first kiddo and just one week from her due date—came in for routine prenatal care. We chatted for a bit about the usual stuff (baby’s movement, discomforts of late pregnancy, signs of labor to watch for), and then started the exam.

I felt the baby’s position (head down—good). I measured her abdomen (normal growth). Then I took out my Doppler to listen for the heartbeat, and… it wasn’t there.

I’m an experienced midwife, so I know where to look. I angled the Doppler one way, then another. I waited. As the seconds passed, I started to worry. It is never this hard for me to find heart tones, especially late in pregnancy. I tried another spot, then another. I frantically searched for the baby.

About thirty seconds passed, maybe a minute. “Is everything ok?” she asked, probably noticing the terrified look on my face.

“Well, I usually find it much more easily than this…” I stammered, trying to buy time. I kept looking, moving the Doppler this way and that. Then suddenly I heard it, very faintly: tick tick tick—140 bpm. The baby was alive.

I’m not going to lie—during those moments, which felt like an eternity despite probably lasting no more than a minute—I was freaking out. I was mentally reviewing her risk factors, wondering if I had missed something along the way. I was hoping and praying that the heartbeat would reveal itself to me, something that felt less likely with each passing moment.

Most of all, I was dreading the moment when I’d have to do the hardest thing I’ve ever had to do in my career: look a mother in the eye and tell her that her baby has died.

Why You Cannot Be Pronatalist Without Being Pro-Mom

Experiences like this clarify something for me. Of course I care about babies—they are profoundly important to their mothers. But babies do not exist in isolation; from the very beginning, their lives are inseparable from the person carrying them. Decades of medical and social science research confirm that a child’s health, survival, and long-term outcomes are inextricably linked to the physical and emotional well-being of the woman who gives birth to them and, usually, raises them.

Day after day, I see moms fight through morning sickness and extreme exhaustion, give up vices, count carbs, miss out on paid work to attend appointments, poke themselves several times a day to stay on top of blood sugars, accept vaccines for their baby’s benefit, carefully consider birth plans, and endure painful labor contractions or surgeries. In some cases, moms risk serious injury or even death to bring new life into the world. They do these things because they want babies, and hope to give them the best start to life possible.

Pronatalists also want more babies. But there is currently only one way to get a baby: through a mom. So in a very important sense, you cannot be pronatalist or pro-baby without being pro-mom. You cannot choose “births” in some abstract sense without choosing the person who is giving birth. The opposite is also true. To look away from the things that threaten a mother’s physical or psychological health during pregnancy, childbirth or early parenting is to make an anti-natalist choice.

Squirrely toddlers are pressed into service in my exam room (pic shared w/ mom’s permission!)

What Holds Me Back From Accepting the “Pronatalist” Label

Recently I was able to put a finger on my reluctance toward the pronatalist movement, helped in part by reading takes by Lyman Stone and Richard Hanania in favor, and Ivana Greco, Jayson Fritz-Stibbe and Patrick T Brown against. Pronatalism literally means “in favor of births.” It doesn’t even specify that the mother and baby remain alive. As a midwife, it is hard for me to accept a label that centers “births” while seeming to minimize or overlook the experience of women who give birth, and the outcomes of their babies. I am told some pronatalists care about such things, but their advocacy for mothers seems quiet to nonexistent.Here are some examples:

Having babies less than two years apart? What could go wrong? No big deal, you can handle it!

Concerning trends in maternal mortality? Exaggerated! Pregnancy and birth are very safe!

You don’t think you can handle a large family? Why not? Your grandma did it, and she never complained! You won’t even notice the difference when you get past three kids!

I’m exaggerating (a little), but this is the vibe I get from the pronatalist movement. It sometimes gestures toward concerns like tokophobia—the severe, pathological fear of pregnancy and childbirth that involves extreme, irrational dread. But is this fear always irrational?

What is largely missing from the conversation is how profoundly the experiences of pregnancy, childbirth and early parenting shape future fertility. During my career, I’ve found that one of the strongest deterrents to pursuing another pregnancy is a woman’s fear—often grounded in past experience—that she will not be able to do right by her child. When birth or early parenting has been medically complicated, traumatic, or inadequately supported, women reassess their preferences and decide to have fewer children.

To make this concrete, here are just a few examples I have encountered in the last month:

• A mother asked me whether she could give birth at a different hospital this time, because every time she sets foot in the hospital where she delivered her first child, she experiences panic attacks triggered by memories of that birth.

• I was asked by my obstetric colleagues to ensure that a 22-year-old mother—who had just undergone her second cesarean section—fully understands that she should never become pregnant again, given the severe uterine scarring and blood loss she experienced, and the very real risk that a future pregnancy could be fatal.

• I read an essay by Angela B. Ryan describing three births to four children marked by substandard obstetric care, including several life-threatening failures—such as not being treated in a timely manner for preeclampsia.

• My professional organization, the American College of Nurse-Midwives (ACNM), has resorted to suing the state of Mississippi, where discriminatory laws make it effectively impossible for midwives to practice—despite a severe shortage of maternity care providers and some of the highest cesarean, infant mortality, and maternal mortality rates in the country.

• A fellow certified nurse-midwife in Nebraska, Heather Swanson, filed a federal lawsuit asking the Supreme Court to strike down a state law making it a felony for herself and other trained, licensed midwives to attend home births.

I wish people understood how often women tell me that a traumatic or dangerous birth—or one in which their choices were ignored—played a decisive role in their decision to avoid another pregnancy. Those of us who want to improve maternity care face an uphill battle and, most of the time, it doesn’t seem like the pronatalist movement cares.

Or, Things the Pronatalist Movement Should Care More About

I sometimes encounter pronatalist arguments—most often made by men—that offer confident projections about ideal fertility rates while paying little attention to the physical and institutional realities required to make those numbers possible.

This is from Richard Hanania in I Am A Pro-natalist:

What is the ideal fertility rate for a society? I don’t know, but would guess somewhere between 4 and 8 per woman. I think 15 is definitely too many, and 2 is too few. Perhaps a fertility rate of 6.5 is ideal from a utilitarian perspective.

I have no objection to large families—they keep me in business. My sister has seven children, all of whom I adore, though it is admittedly, much easier to be an auntie to seven than a mother of seven! And a noticeable portion of my Substack audience consists of mothers of many children, who tend to love midwives (we love you back!)

But I thought the goal of the pronatalist movement was to recover from a total fertility rate of roughly 1.6 to replacement level at 2.1, or maybe to get back to the desired family size of 2.7—not to propose an “ideal” of six or seven children per woman!

There are plenty of practical reasons most women don’t want six or seven kids, but I’d like to hone in on one of them—the state of maternity care.

C-section overuse

Start with the fact that roughly one in three births occurs by cesarean section in the U.S. I’ve already argued that C-section Overuse Is Suppressing the Birth Rate, but suffice it to say that cesareans are major abdominal surgeries with cumulative risks that limit the number of babies a woman can safely have. Yet the dangers of repeat cesareans are almost never acknowledged in pronatalist discussions, which focus entirely on more babies, more babies, more babies.

Meanwhile, women give birth within a medical system where access to vaginal birth after cesarean (VBAC) is hard to come by because it is banned or severely restricted by many hospitals. A recent survey showed that only 16% of U.S. counties offer pregnant people the opportunity to attempt VBAC. But Does Access to VBAC Affect Family Size? Based on my research and clinical experience, the answer is a resounding YES! Yet I see no pronatalists fighting for the women who are required by doctors and hospitals to have major abdominal surgery to give birth, or any attempts to count the babies that are perhaps not being born because of these policies.

Can we acknowledge that a fertility target of six or seven children translates directly into several major surgeries, with sharply rising risks of hemorrhage, placenta accreta, hysterectomy, and death with each one? Unsurprisingly, a lot of women say “no thanks!” and request a tubal sterilization procedure with their repeat C-section.

If my anecdotes are unconvincing, consider new research by Haley Wilbert, who used Army health claims and medical records to study subsequent fertility in people who had a C-section. Her study is called After the Cut: Cesarean Delivery and Subsequent Fertility and here is from the abstract (sections in bold, emphasis is mine):

Among women undergoing C-sections that were likely unplanned, we observe a reduced probability of subsequent childbirth within four years by 28% to 34%…. These results suggest that the birth experience surrounding C-section delivery plays a critical role in shaping future fertility decisions. To explore mechanisms, we examine short-term maternal outcomes and find that unplanned procedures are associated with increased hospital readmission and mental health visits, consistent with the influence on reproductive behavior running through physical and psychological pathways. Because childbirth in the military setting is nearly costless and insulated from financial incentives, our estimates likely represent a lower bound on the effects in the broader population, among whom repeat C-section carry higher financial and logistical burdens.

Which brings me to my next point…

The sacrifices of men and women who have children are not the same

Later on in his pronatalism essay, Hanania names his sacrifices as a father:

In my own life, I’ve sacrificed a lot to have children. I don’t get enough sleep. I live on the West Coast when I should be out East. I should travel a lot more, write about my experiences, and do more in-person interviews. But I had kids, and have lost some status as a result given our current value system. It should be adjusted to reward me for creating new life.

Look—I appreciate the sacrifices of fathers, which can be significant. But it is difficult to read something like this without noticing how starkly different those sacrifices are from what I see women going through every day. In just the last week, I have cared for a patient who lost nearly two liters of blood during a repeat C-section, and another who asked for a “return to work” letter at four weeks postpartum. The sacrifices I witness women making to have children are orders of magnitude greater, and any conversation about pronatalism that does not acknowledge this feels incomplete.

When pronatalist arguments focus on the personal sacrifices of fathers while calling for dramatically higher fertility rates—four, six, or even eight children per woman—they obscure the fact that these costs scale very differently by sex. For women, each additional child compounds physical risk, career interruption, and long-term economic loss. Against this backdrop, appeals to social “rewards” for men who have children ring hollow when women are not even guaranteed the basics: paid maternity leave, breastfeeding support, economic security during periods of unpaid caregiving, and the ability to give birth without incurring large medical bills. When it comes to having kids, women make the deepest and most enduring sacrifices, and are so often taken for granted.

Since I’m just a regular, non-homeschooling mom with a meager 3 kids, I’ll leave this to Ivana Greco from Why I am still not a pro-natalist:

I have four children myself, and it is a huge job. I absolutely do not want my elected officials weighing in on whether it would be ideal for me or any other woman to have more (or fewer). Each additional pregnancy is serious, significant work. Unlike what some people online will tell you, I find that there is an enormous difference between having three kids and four kids, and I am sure that should we add a fifth child to our family one day, that would also be a huge shift.

On that note…

You actually need buy in from women to fix the low birth rate

There is a basic biological reality at play here: a single man can father many children, but a single woman’s reproductive capacity is limited by gestation, recovery, and a finite window of fertility. The total number of children a society can produce is therefore capped not by the number of willing men, but by the number of women who are able—and willing—to bear children. This fact is so obvious it feels strange to state it outright, yet it is routinely ignored in pronatalist discourse.

Which brings us to Elon Musk.

Yes, an extremely wealthy man can usually find willing women with whom to have children. But from a population-level perspective, this does not increase the birth rate. It merely pulls women who might otherwise have partnered with other men into the orbit of one very powerful one. The number of wombs does not change. The bottleneck for fertility remains the same.

Musk feels himself to be a kind of pronatalist exemplar: a man “doing his part” by having many children. But a closer look at his behavior reveals how thin that claim really is. With his first wife, he conceived five children—a set of twins and a set of triplets, via IVF, all male. According to his trans daughter (with whom he no longer has a relationship) and his first wife, Musk uses IVF to select boys. From a pronatalist standpoint, this is not just morally fraught but bizarrely counterproductive. If women are the limiting factor in future fertility, engineering a legion of sons shrinks, rather than expands, the reproductive base of the next generation, and if a lot of people did this, we’d be in big trouble!

We have already seen where systematic son preference leads: distorted sex ratios, social instability and long-term demographic problems in countries like India and China.

Sign posted inside a maternity hospital in New Delhi, India. When I visited with a delegation of midwives in 2024, I was struck by how ubiquitous warnings against sex-selective abortion were in clinics and hospitals. Must be a big problem there.

I appreciate Patrick T Brown naming it here:

If you cannot condemn Elon Musk’s modern-day harem, using surrogates and NDAs producing his “legion” of genetic heirs, your version of pro-natalism is different than mine.

Just as importantly, Musk-style fathering turns a lot of women off. Again, Ivana Greco:

A worst case scenario, in my mind, is that having babies suddenly becomes politically polarized, and thus liberal women are shifted further away from having babies in reaction to their disgust at people like Elon Musk trying to raise the birth rate. Here, in my mind, is where the pro-natalist movement may end up being ironically counterproductive.

Lyman Stone wasn’t too concerned about that:

The real problem is… conservatives having too many babies! We wouldn’t want liberal women to be disgusted; won’t someone please think of the liberal women? We’ve got to stop being in favor of babies until we can figure this thing out.

But here is the inconvenient truth. You cannot be “in favor of babies” while dismissing women’s reactions, values, or experiences. Whether you respect them or not, agree with them or not, the fact remains: raising the birth rate requires women’s participation. Until artificial wombs take over—which hopefully won’t happen anytime soon—any serious attempt to increase births depends on women willingly choosing pregnancy, childbirth, and motherhood. Any movement that alienates women while claiming to care about births is working against its own stated goal.

So there is basically no way around it: we need these women to choose to have babies with these men. So what’s the plan? (graph source):

Men have always been more conservative than women and somehow we usually make it work

My Optimistic Conclusion: Actually, Women Really Want Babies Too

I think low birth rates are a solvable problem because, it turns out, women want babies too. Feeling a pull—or at least a curiosity—toward having children is part of the human condition, and for good reason. Babies are cute, but even better, they grow into funny, sarcastic, opinionated people who secretly troll you online and buy you “#1 Mom” mugs for Christmas. They become travel companions, co-conspirators, and eventually, members of your adult support system. In a world that is increasingly lonely, having kids is an antidote.

The problem isn’t that women don’t want children. It’s that they conclude that the cost—to their bodies, their mental health, their work, and their sense of self—are too high or too poorly supported. If those experiences are safer, more respectful, and better supported, many women are happy to have children. So if we want more babies, a good place to start would be caring about the experience of the women who have them.