 Good morning, Thursday. I'm Jay Fiedel. This is ThinkTech. More specifically, this is much more on medicine with Nadine Tensao. She's a pediatrician, and we are so happy to have her with us. Thanks for joining us, Nadine. Yeah, thanks for having me. So we're asking today, what happens with the birth rate in COVID time? And it's a very important discussion. And there's so many things that we don't know. I mean, we, the community doesn't know about this and the bell curve and the way, you know, the way the population, the demographic, the demographic has changed and has changed and is changing. So I'm so happy that you're here to talk about it. So can you give us some background? You know, what have been the trends anyway in terms of birth rate, pregnancy rate? Because this has a profound effect on us. You know, it's an interesting question you're asking, because there are some things that we know, because we've had time to measure them. And then there's some things that we're just starting to see a trend. And there's early data, but there hasn't been enough large data, large studies to show, is the information real and what do we think of it? So you're bringing up actually two things on the decrease in the birth rates. And just recently, I'm not sure if you've seen it. Quite a few countries are also seeing decrease in preterm infants. So with regard to your first question, our birth rates going down, this is actually not new. We've been seeing birth rates go down for the last decade. And now I think there's a secondary question is what impact will COVID have on the already downward trend. So for the last decade, we've seen a decrease in birth rates, particularly in developed countries, the United States, Europe, Japan is at the top of the list of having the lowest birth rates for developed countries. Countries like Niger. And there's a few other countries in Africa that have the higher birth rates. Well, they'll have one for every mom, anywhere from five to six children, whereas on Japan, the United States, and even Germany will have more like one to two at best. And they're also struggling with their younger reproductive age women, putting off having children later and later. So each year we're seeing a decline of one, sometimes it's 2% and in some countries more of the general birth rate. And this is really important. More so I think economically than from a clinical standpoint, because as a population or as a country, you do want your population to continue. If you don't, it has a significant impact in your economic structure, your labor force, considering that the labor force comes from the youth, not the older. And there's a sense of wanting to continue. Does that help? Oh, yeah. Well, let's let's unpack it a little bit. One thing, you know, I would ask you is my favorite question of all, and that is, why? Why are people having, you know, especially the dichotomy you mentioned, you know, the more developed countries have fewer children, the less developed countries have more children. We knew, I guess, that Europe, the fertility rate is down low. The US was declining in Asia, especially Japan declining. And maybe other parts of Asia, it's not declining. I don't know that. But the question is, what is what's going on here? Is it because, you know, it's not intuitive, you think that a prosperous developing country would give you all the reasons, including romance, including that white picket fence image, you know, you know, you get you have romance and then you get married and you swear to each other you're going to develop a family and let's go for it. And that doesn't happen. Something has changed. What has changed? Like all issues like such as this, it's not one thing. And you can imagine the developed countries themselves have actually put an incredible amount of resources to look and find what are the factors. Things that have kind of floated to the top that seem to be impacting the decision, not only to have children, when to have children and how many have been some things of whether or not it negatively impacts a woman's economic power, or her ability to, not just whether she can move up in the professional ladder, but also her economic security. What things are in place in a country that is actually is a deterrent if she gets pregnant? Does she lose her job? Does she lose her insurance? Does she then get a sideline in a professional career? And everything depends differently on which socioeconomic bracket you're speaking to. But even if you're not speaking to a group of people that their profession is the highest concern, if they are out of the workforce and they can't afford to have children. So the decision to have children has a very, has a significant economic question for any individual. And if their country or their societal network does not support the decision, it deters them from doing it. So you'll see countries like Japan and Germany who have done things that guarantee both maternity leave as well as parental leave so that the burden is not entirely on the woman. They'll have subsidies during the time that they're pregnant. Health systems, health disparities are another concern. Countries that have, and I'll back up a little bit, we're a perfect example where we have a significant number of people who have health insurance. But the downside is that you need to be employed to have health insurance. And if there's anything about having the child or being pregnant that will jeopardize your job, you have to think twice whether or not you're going to keep the job, I mean, excuse me, decide to get pregnant. And when you do decide to get pregnant and you possibly lose your job, or have to take less hours, is there a social healthcare safety net to fall back on? Here in Hawaii, we have quests. In Germany, they have a socialized health system, but in places that those safety nets are not in place, those are the things our individuals have to decide upon. And those are just some. Well, that takes me to my second favorite question. Sex. It's my second favorite question. What about sex? And I read recently that sex was down. That sex plays a part. I don't want to tell anybody something they don't know, but sex plays a part in pregnancy and childbirth. And sex is down. Why is sex down? I'll answer it first. I'll answer your question, but I'm going to throw out some interesting data that I think would help answer that. When they look at the birth rate by age group, greater than 38, 40-year-old women, their rate has not gone down. Is our teenagers, we've been working so hard for decades to have teenagers not have sex and not get pregnant, and it's down, and now we're upset. But it's a general trend that our adolescents are young 20s, and people are pushing into their mid 30s before they're deciding to have children. Some of this is a personal decision, but we're also showing that they're actually less sexually active. Some of this is unique to the United States, but even when you widen your view to the entire world, our younger people are having less and less sex. And that is a separate question. The studies have shown that this generation of young people are declaring loneliness and not having a significant close person as either a friend or a serious relationship with higher numbers than we've ever seen before. And sex comes with that right afterwards. Otherwise, you're talking about having a very impersonal sexual encounter. So with the close relationships going down, we also see sexual activity going down. Yeah, this takes us to a number of pieces that I've seen about how young people, especially young people get involved with the relationships on their phones, on their smartphones. That's very, very sort of thin, reduced quality of relationship, even if they're talking to lots of friends and having very personal discussions, it's still not the same. You know, you can't get pregnant with a phone. And I'll go on record about that. And so, you know, the relationship, nature of relationships was changing, had changed prior to COVID. And then you get into this continuum with COVID, where, you know, even if you wanted to have personal contact, you really can't. It's not as easy. It's, it's frightening. It's against the law. So let's talk about COVID. How has COVID actually entered into this whole area we've been discussing? Well, COVID, I think when we first started it, there's always been a bit of a quip. You have a baby boom. So we wouldn't see it this year, we probably see it nine months from now. Or nine to 10 months from now, maybe after historical periods of crisis, right after wars and such that people hunker down, either because they were in close proximity, or is this a way of relieving stress with sex. And then there's a surge in the birth rates right afterwards. This is where we started this as a country in January. I think it impacted us around spring break in March. And so we've had a number of months to watch this. And now the thought is actually the opposite, that we're going to see a record low during COVID. I believe that instead, other factors are going to impact the both the decision not to have sex and then the natural effect of not having sex and then not having becoming pregnant. And what I mean by that is, unlike other periods in time, people feel, I believe, more uncertain about their economic security and are purposely making the decision not to get pregnant. They also feel an uncertainty about the safeness for it. So they're also deciding not to get pregnant. And because these hesitance and then you conclude the lockdown, the decreased availability sort of get out there and see your friends. Most people, if they're not entirely isolated, have created a very small cohort in which they're interacting with intimately, or seeing on a regular basis. So all those opportunities have been suppressed. And the thought is, is 2020 will not see an increase in births as another crisis, but we'll actually see a profound decrease. So the whole thing, I think it probably does with the whole thing feed in about how we warned them about sexually transmitted diseases. We warned them about, you know, every single disease, including AIDS. And they had to be very careful, they had protection and all that. And although they may not have accepted it fully before. Now it sort of feeds into that decision process. Like, at the back, at the back of their brain, something is saying, this is bad. Don't do this. There are risks, all kinds of risk to too many risks. Is that part of it? You know, you asked me that question, I think I'd be giving you my opinion, because I've never actually seen a study that specifically address the fear or the impact of sexually transmitted disease on an adolescent or young person's decision to have sex or get pregnant. So my thought is, is, you're probably right in a hole that it becomes one more thing that you think twice about before you engage in that sort of moment of passion. You think, oh, maybe I should use some sort of protection, maybe I should reach for that condom. And with all of that, that they are then protected because they understand it is such common knowledge how one gets an STD. What you have is also the reduced risk of accidental pregnancies. I think young women are being taught from a much earlier age to feel a certain amount of empowerment. And it is no longer considered promiscuous to come into either your doctor's pediatrician or adult doctor's office and say, you know, I'm thinking about using birth control. My 17 year old or 16 year old patient will look me in the eye, and they don't expect me to blush any more than they're blushing on the question, I'd like to start birth control. And I would say at least half the time, their mothers, unlike two decades ago, their mothers are right there and saying, you know, I support her decision. You know, I hadn't thought about this until just now, but we do have the whole Roe v. Wade phenomenon. We do have a fairly large social group in this country for religious or maybe political purposes they oppose abortion in every way shape or form including murdering people who do abortion. I'm not sure the medical community is well familiar with that process and, and I'm wondering whether that feeds into this I mean the religious or political objection to to abortion. How does it play in terms of looking at the birth rate. I've got to think about that. I think in terms of the decision to have sex, the decision to choose if you're going to have one or how many children you plan to have. I think that's separate than Roe v. Wade. I think, I think it's a significant discussion. I think it requires a lot of thought, but I think the way it would be connected to your question about the decreased birth rates. I think what has had the biggest impact is women maturing into the understanding that they have a right to make decisions about their body, their sexuality, when they're going to get pregnant. How many, and with that, that pause that thought there's less, there are probably less accidents less decisions to maybe have children very early like in your 20s, as opposed to maybe waiting when it might be a little bit more practical and I'm not saying you cannot or should not have children in your 20s but it starts to factor in. I think that when the circumstances to have an abortion do arise, I think that's a separate decision, whether it be by an accident and an inappropriate time or rape and incest. I think the two are not necessarily directly connected. And I'm saying they're uncoupled from each other but I don't think the two are directly connected. Here's the thought and you're obviously much closer to this than I am but I think with the objection to Roe v. Wade with the objection to abortion. I'm not sure if it's political as much as religious, this notion of abstinence. We don't want, one of the ways to avoid an unnecessary or rather an unexpected birth is abstain. So that's in the list of things that they would teach you, abstain. And so, an inherent in that seems to me, it's a social question, inherent in that is this sort of old fashioned notion that sex is bad. Abstention means sex is bad. You know, it's not the emancipated woman at all. It's the reverse. And if you teach people in large numbers about, you know, opposing abortion and abstaining among other ways to stop, you know, the need for abortion. Then you're really teaching them sex is bad sex is bad. You know, they don't engage in sex abstain from sex is what it is. How does that feed into this? I think when I read the nationwide data, I have a tendency to agree with you. There's still that overarching Puritan philosophy of how sex should be viewed and I think it is taught and maybe somewhat imposed on our young. I'm going to say that it feels in contrast to what I see here in Hawaii. I think for the most part, and I think it's because we're as a state and as a culture such a family oriented society. I raised earlier if which countries had the highest birth rate. When you rank which ethnicities have the highest birth rates guess who was at the top of the list Pacific Islanders and Hawaiian native Hawaiians. And my point where I'm going with this is, I tend to agree with you. But if I put it in the lens that I see and I practice here in Hawaii, I don't know if that's true. Sexuality for the most part, I'm not saying it crosses over every ethnicity that exists here in Hawaii. For the most part, it seems to be viewed in a fairly healthy embraced manner, something in which we share and family and even to have children a little bit young out of wedlock. To me does not feel it doesn't it doesn't carry the same amount of shame, or those religious overtures that I've experienced when I've lived in other parts of the country. I quickly there might be a little bit of anxiety. They may decide to have an abortion but if they don't very quickly multi generational families surrounds the young woman and often the young man and their their task is to raise that child. Children are a good thing and family is a good thing and in immigrant families, it's a good thing. Let's talk about the fertility curve for a moment. But we talked before the show about what you know what a an appropriate fertility curve would be facility number, excuse me, which, you know, ultimately results in the in the bell curve of age demographic. It would not if it was theoretically at 2.0, you would be able to perpetuate the population doesn't work quite that way doesn't know it doesn't work quite that way and I think the anxiety for people who more and this is outside my expertise it seems to be more of an question and a population health question, but apparently we've been closer to 1.9. And each year we seem to be dropping about 1% on the world. And so we're not maintaining that and I think I alluded a little bit earlier. Why is that important aren't we an overpopulated world and shouldn't we be tapering our birth rate anyway. And that's true if we were to speak in world health population or world politics but when you draw drill it down to individual countries. In order for them to maintain their economic might and the other things that make countries powerful. Maintaining your population is apparently part of the equation. And when they see them drop their willing to put a significant amount of monetary resources to maintain that 2.0. I think this is an appropriate time for me to talk about Victor Orban. Victor Orban is the dictator in Hungary. There was a peace and I think it was in 60 minutes not too long ago about what he was doing. He had decided that it was to his political interest to have a greater number of children in Hungary. He was embarked on an incentive plan. And it's monetary. If you want to have a child, you get a van. You get a van. Free van. And that encourages a lot of young people to have children and you get tax breaks and all kinds of gifts are showered on you by the government of Hungary. There's something nefarious about this too. He's trying to manipulate the population. He's trying to be kind of self directed in a directed person and you reject the gifts. You know, you're on the wrong side of the tracks as far as he's concerned. He's trying to rebuild his economy. He's trying to rebuild his social structure, his demographics. It's truly out of brave new world or 1984. In terms of science fiction is what it is, but it's happening right now. So Nadine, do you think this is going to happen if we don't have enough population to maintain our economy. We see that for the lack of either, you know, children born natively in the country or immigrants and that's another question we should discuss coming into the country that our economy is failing. And I think you can almost say that that's already the case. And do you do what Victor Orban does? You know, it's so funny that you said that because I think all of us when we're reading data, our mind goes a little bit to the Ray Bradbury or the science fiction of it all. I think what most people in 2020 would relate to is the handmade entail because the manipulation can go in both directions. We're attempting to increase the population. It could go into being selective of who can populate and not populate. And yes, don't forget the Chinese. Yes, we are a cultural revolution. We will only want men, not women, whatever. Oh, I thought you were referring to what was going on to the Muslim population, the Uighurs in that too. Well, there's one child but what they're doing is, for instance, they're locking away an entire group of people and that would have an impact over time. But to answer your question. Yes, it worries me. And I guess as long as there's evil, there's the potential of that if it's when we allow evil to be in too high in our leadership level. We do not have, I don't want to say barricades, but barriers that allow some things to move in science, but go unchecked can be used in very nefarious ways. There is another way that I think I would look at this for a second. It doesn't have to be necessarily a dictator is using it for their, their specific purpose. One of the studies that came out began to look at the opposite. What things we have placed in society that make it more challenging for women to want to, not even women, let me be careful. While women do have a give birth and make a lot of decisions on when and how to expand the family. This also affects a couple or a family when they decide to expand their family. And what things do we have in place in society that deter that versus encourage that. You know, do we make it more difficult for families to be anything other than one child or two children if some because every child is an expense to a certain extent. Do we penalize families or do we specifically penalize women. So before we get into the singular extreme of the Hungarian dictator, I would almost argue that we need to look at what have we done to make it truly a joy, a blessing and an added benefit to an individual since we as society on a whole are benefiting from families growing and being healthy. Yeah, we may have forgotten a little of that you know there's that earthy quality about the hearth and the home, all those you know old values and we seem that they seem to have slipped on this. Let me raise another thing I saw on 60 minutes I think it was, and that is Italy, Italy. I mean you think of Italy as a sort of picture a statement of fertility, but that Balabusta Italian woman and not in the home you know cooking her pasta and all this and having multiple children all around the place. Now, in many villages and towns in Italy. I suppose this is more pronounced in the rural areas. They don't have children. It's economic I suppose mostly but whatever that that Balabusta Italian ethic was it's diminished, and they took, they took the camera for a walk into the local hospital, and the maternity ward was empty. There wasn't anything happening, no, no pregnancies and no childbirth. So my question to you is, this has got to, this is this phenomenon has got to affect health care. It's got to affect you Nadine and pediatricians. It's got to affect the way we deal with keeping the population healthy. What are your thoughts on that. Well, I'm going to tell you, I'm going to leave it the answer more as a teaser. I think COVID will bring a lot of this to a head. Now that we've had a lot of lockdowns and people are going home and spending more time with their family. I think they're starting to question where their priorities are. And what does home and family and being with children look like when you have time. So I think when we're done with this COVID, I really believe there's going to be a lot of pushback on what we're going to demand of our laws and our society, so that we can do what we enjoy the most, getting home on time for dinner, hanging with our kids, not pressuring them to get stuff done because we have to run back to do work in the wee hours of the night before the following morning. So to answer your question, I think in the next year we are going to have enough data to be able to look back at this and draw some really real conclusions. It's been a lovely thought. Thank you for that. That touches me. But let me let me offer you this though I mean we have an increase in domestic violence here I don't think anybody will argue that. Yes. And we have, you know, people who beat up their, their, their significant other on a regular basis. And so what you have is people living together, often in very tight circumstances, especially those Pacific Islanders we spoke about you know, who catch COVID because they're living in very contained living circumstances. It's hard to stay balanced. It's hard to stay friendly. Now, let me offer also the thought that I know a lot of people who are spending more time with their families and their children than they ever have in their lives. It's that value thing you were talking about. They are learning who their spouses they are learning who their children are they are learning how to rework the priorities. The marriage is better. The marriage is more robust. It's more residents more is more empathetic and all that. The question is which side of that equation will prevail. I think it's a tension, don't you. I think it's we as a larger society, and who we pick is for leaders that will help us that they recognize that tension. And what we can do as a society to support those priorities because. It's not enough. We'd like to think so it's not enough for you as an individual to value that as a priority. We as a society have to value that as a priority and to give space for it, even though you may not be able to measure it on an accounting spreadsheet. I mean, with regard to domestic violence and even incest or other forms of abuse. Right now it's unchecked, and you're 100% correct in the space of wanting to address something I think we're going to be in trouble. We're going to be a lot of unreported on a managed incidences, but if you dial back, not in the space of wanting to catch people, but what allowed domestic violence and child abuse and all of those things to occur in the first place if we're allowed the ability to step back and could put into place things that support families that don't drive that tension that allows those types of activities and to breed and occur. That might be a way that we could also bend the curve without necessarily jailing someone as the endpoint, either allowing it never to happen or supporting them way before the crisis occurs. So, from your lips to God's ears, Nadine. So we're about out of time and I want to ask you one last question you, you're at the intersection of this because you're a pediatrician. And we talk about family in so many ways where we're talking about children, we're talking about the, you know, the hearth, so to speak. And you see that happen, perhaps more than any other specialty you see that happen medically, socially, economically you see it all happen. It's an enviable position in a way, although I'm not sure, you know, you would call it enviable but I think it's important in our society and I ask you this final last question. What message about childbirth and family in COVID. Would you leave with people now. I'm going to reframe your question, because I don't think if I were to push any thought, or ask anything of my families, it wouldn't be have more children. It would be spend time with your family and understand the value of your time with your family. And if that result or that experience, then inspires you to have more. That's where the desire to have children should come from. And when I speak about family, family doesn't necessarily have to start with you and another as a couple. It often starts with just even spending more time with your parents or your grandparents and understanding the value, the beauty and the power of that locus, call the family. And then the desire to have more or to build your own comes out of it. How lovely. They deem Tensau, MD, pediatrician, pediatrician, Extruded Air and Altruist. Thank you so much for joining us. It's nice being with you. Take care.