Japan has spent 50 years fretting about its low birth rate and declining population but new prime minister Yoshihide Suga has hit on a different solution: fertility treatment.
In his leadership campaign, Mr Suga called for in vitro fertilisation to be covered on national health insurance. The prime minister wants to make it affordable in a country where the average age of first-time mothers is now above 30 and nearly one in five couples has had tests or treatment for infertility.
Mr Suga hopes the policy will raise Japan’s fertility rate, which stood at 1.36 children per woman in 2019. The fertility rate has been below the replacement level of 2.1 since the 1970s, locking in decades of future population decline with profound consequences for Japan’s society, economy and national security.
But while subsidies for fertility treatment reflect a slow shift in Japan towards supporting parents rather than criticising the childless, experts said it still did little to address the economic insecurity and gender inequality that discouraged marriage and raising children.
“To lower the hurdle even a little bit for any family that wants a child, we should work rapidly to include fertility treatment on health insurance,” said Mr Suga last week, framing the policy explicitly as a “countermeasure to the falling birth rate”.
Infertile couples struggle in Japan, said Akiko Matsumoto, who campaigns on their behalf as head of a charity called Fine. “There are four burdens: body, mind, money and time.”
Not only is the treatment physically draining and psychologically stressful, but there is little financial support and employers grudge the time off for medical appointments.
“If someone tries three or four rounds of treatment, it can easily run to ¥4m ($38,000),” she said. Ms Matsumoto has lobbied the government to provide insurance coverage for fertility treatment but said the details were critical. A cost cap limiting available treatments “would harm patients”, she said.
Even if the insurance cover is generous, analysts are cautious about how much it will affect birth rates. “It’s very hard to estimate but in 2018 there were around 57,000 births due to IVF. That could increase to 100,000 [if covered on insurance],” said Isao Takumi, senior researcher at the Meiji Yasuda Research Institute.
One in every 16 children born in Japan today is a result of IVF and the figure has risen fivefold in the past 20 years. “I think covering fertility treatment is an excellent idea but it depends a lot on the details of the policy,” said Mr Takumi.
An extra 43,000 children a year would make a difference, but Japan was shocked last year when the number of births in the country fell to 865,234, compared with 918,400 in 2018 and more than 2m at the early 1970s peak.
After reaching a trough of 1.26 in 2005, Japan’s fertility rate recovered to 1.45 by 2015, but it has since fallen for four years in a row. Current fertility is well below that assumed in projections that Japan’s population will decline from 127m in 2015 to 88m by 2065.
Sumio Saruyama of the Japan Center for Economic Research, who co-wrote a proposal to stabilise the population by matching French levels of childcare and family spending, said that being able to combine work and family was a necessary condition for Japanese women to have more children.
“The fundamental cause of the falling birth rate is the rise in women’s economic power,” he said. Nations around the world have experienced the same phenomenon as the opportunity cost of having children rises for well-educated, high-earning women.
But Japan’s culture of long hours makes it difficult to work and look after children, and childcare is expensive and hard to find, while surveys show that Japanese men do less work in the home than their counterparts in Europe or the US.
Mr Saruyama said he had not studied the impact of fertility treatment on birth rates. However, his analysis suggests the cost of giving birth is less relevant than the opportunity cost of lost earnings.
Although Mr Suga does not hide his ambition of raising the birth rate, he is also careful to avoid any suggestion of state interference in private decisions about whether to have children. The subject is a taboo in Japan since the militarist government of the 1930s suppressed birth control and made an ideology out of increasing the population.
Ms Matsumoto is delighted by the public attention being paid to fertility treatment. But her mission is to help those who desperately want a child and she dislikes the idea of linking that to birth rates.
“People aren’t having children for the sake of the country,” she said. “They don’t want to be told to get fertility treatment just because it is available. They have a right not to have children as well.”