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Climate change, mental health, and reproductive decision-making: A systematic review [1]

['Hope Dillarstone', 'Institute For Global Health', 'University College London', 'London', 'United Kingdom', 'Laura J. Brown', 'Elaine C. Flores', 'Centre On Climate Change', 'Planetary Health', 'London School Of Hygiene']

Date: 2023-12

The impact of climate change on reproductive decision-making is becoming a significant issue, with anecdotal evidence indicating a growing number of people factoring their concerns about climate change into their childbearing plans. Although empirical research has explored climate change and its relationship to mental health, as well as the motivations behind reproductive decision-making independently, a gap in the literature remains that bridges these topics at their nexus. This review endeavours to fill this gap by synthesising the available evidence connecting climate change-related concerns with reproductive decision-making and exploring the reasons and motivations behind this relationship. A systematic review using six databases was conducted to identify relevant literature. Included studies reported quantitative, qualitative, and mixed-methods data related to: (1) climate change, (2) mental health and wellbeing concerns, and (3) reproductive decision-making. Findings were synthesised narratively using a parallel-results convergent synthesis design and the quality of studies was appraised using three validated assessment tools. Four hundred and forty-six documents were screened using pre-defined inclusion criteria, resulting in the inclusion of thirteen studies. The studies were conducted between 2012 and 2022 primarily in Global North countries (e.g., USA, Canada, New Zealand, and European countries). Climate change concerns were typically associated with less positive attitudes towards reproduction and a desire and/or intent for fewer children or none at all. Four themes explaining this relationship were identified: uncertainty about the future of an unborn child, environmentalist views centred on overpopulation and overconsumption, meeting family subsistence needs, and environmental and political sentiments. The current evidence reveals a complex relationship between climate change concerns and reproductive decision-making, grounded in ethical, environmental, livelihood, and political considerations. Further research is required to better understand and address this issue with an intercultural approach, particularly among many highly affected Global South populations, to ensure comparability and generalisable results.

Copyright: © 2023 Dillarstone et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

1. Introduction

Climate change is often regarded as “the biggest global health threat of the 21st century” [1] [p.1693] due to the direct threat of rising average temperatures and climatic hazards, paralleled with indirect effects including water and food insecurity and changes to disease epidemiology. At the same time, tackling climate change is also posited as “the greatest global health opportunity of this century” [2] [p.1861], as mitigation and adaptation responses can reduce disease burdens, alleviate poverty, and confront global inequity. Climate change is already having a ubiquitous impact on human health, with adverse effects projected to increase even further, albeit with a degree of heterogeneity between countries and populations [3]. A recent emergence of studies and policy are exploring the link between climate change and mental health. This came to the fore with the coining of new concepts such as ‘eco-anxiety’, fast becoming a buzzword in public discourse as it describes the “chronic fear of environmental doom” [4] [p.29] that continues to proliferate in the minds of individuals worldwide [5]. Other analogous terms have also emerged including climate trauma [6], ecological grief [7], and solastalgia [8], which all describe a form of emotional response towards ecological issues associated with climate change.

Over the last decade, a novel connection has been formed between these psychological effects of climate change and human reproductive decision-making. Anecdotal evidence from news outlets, surfacing largely from countries in the Global North, has revealed a growing number of individuals reconsidering their reproductive decisions in light of their concerns about climate change [9, 10]. Yet, empirical research studying the intersection of climate change, mental health and wellbeing, and reproductive decision-making remains a nascent endeavour. It is important to note that although the Global North and Global South divide is critiqued for being oversimplistic [11], the terms are referred to throughout this review in favour of the ‘developed’ and ‘developing’ dichotomy that implies an inherent hierarchical nature.

This study aims to fill this gap by synthesising the current empirical evidence investigating the relationship between climate change-related concern and reproductive decision-making. As the health effects of climate change become ever more pervasive, it is logical to assume that these concerns will continue to diffuse among populations and potentially influence reproductive decisions [12]. Consequently, this matter has far-reaching implications across multiple disciplines including public health policy and environmental politics, emphasising the immediacy of this research. A systematic review was conducted and a total of thirteen studies were identified for inclusion (Fig 1 and S1 Checklist).

1.1 Climate change The United Nations Framework Convention on Climate Change (UNFCCC) defines climate change as being, “attributed directly or indirectly to human activity that alters the composition of the global atmosphere and which is in addition to natural climate variability observed over comparable time periods” [13] [p.7]. Despite ongoing debates in the media regarding the anthropogenic nature of climate change, the Intergovernmental Panel on Climate Change (IPCC) reported with 95% certainty that human activity is the primary cause [14], leading to a consensus that it is “marked by human influence” [15] [p.119]. Human activities, notably the burning of fossil fuels, have led to a significant increase in greenhouse gas (GHG) emissions, and consequently, the global surface temperature is currently averaging 1.2°C warmer compared to pre-industrial times (1850–1900) [3, 16]. With this alarming rise, climate change has been inextricably tied to the intensification and increased frequency of climatic hazards worldwide such as heatwaves, storms, drought, and flooding. Together with indirect effects including food and water insecurity and increased air pollution, climate change is having a detrimental impact on the social and environmental determinants of human health [17].

1.2 Climate change and mental health Climate change has been expedited to one of the top priorities on the international political agenda over the last few decades following scientific evidence connecting it with adverse health outcomes [18]. These health effects are continuing to unfold across the globe with reported rises in premature deaths, infectious diseases, non-communicable diseases, and mental illnesses all attributed to climate change [2]. Whilst causality cannot be easily inferred as drivers of poor health are often complex and intertwined, the empirical evidence undoubtedly shows that climate change is a contributory exacerbating factor. Whilst impacts to physical health have historically been the focus of academic inquiry, climate change also impacts mental health both directly, from exposure to climatic hazards, and via numerous indirect pathways including loss of livelihood, displacement and forced migration, and armed conflict and interpersonal violence [19, 20]. These risk factors can lead to the onset of mental health conditions and adverse psychosocial outcomes such as depression, anxiety, substance use, and suicidal actions, or have a compounding effect for those already living with these conditions [21]. Moreover, these effects are experienced disproportionately by the most disadvantaged members of society including people with pre-existing chronic disease(s) and/or disability as well as minority groups, people with low-incomes, and women and children. Adopting an intersectionality lens, which considers the systems of privilege and oppression resulting from the intersection of an individual’s multiple social identities [22], serves as a reminder that many people occupy a combination of these marginalised identities which may work in tandem to further increase their vulnerability to climate change [23]. Mental health is broadly defined as “a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community” [24] [para.1]. Under this comprehensive definition, contemporary climate change research is also beginning to take heed of less pathological responses arising from an awareness of the slow and gradual changes to environmental conditions [25]. This phenomenon is now commonly referred to as ‘eco-anxiety’, which encompasses a range of negative emotional responses including fear, anger, guilt, dread, and anxiety itself towards the climate crisis and ensuing environmental deterioration [25]. One international study on climate anxiety surveyed 10,000 16-25-year-olds in ten countries (Australia, Brazil, France, Finland, India, Nigeria, Philippines, Portugal, the UK, and the USA). They found that over 50% of respondents felt one or more of the following negative emotional responses towards climate change: feeling afraid, sad, anxious, angry, powerless, helpless, and/or guilty [26]. Alternative terminology has also emerged to describe this affective dimension of climate change including solastalgia, which describes “the distress that is produced by environmental change impacting on people while they are directly connected to their home environment” [8] [p.S95], and ecological trauma which is the “experience of witnessing–consciously or not–the pervasive abuse and destruction of the natural world” [27] [para.2]. Whilst these new concepts are gaining traction within public discourse, there is still limited empirical evidence that can verify the true extent or prevalence of these psychological effects, particularly within Global South settings. Attempting to quantify and measure emotional responses to climate change is not a simple feat considering the diverse array of mental health outcomes. However, one framework is prominent in the literature–the New Ecological Paradigm (NEP). The NEP is a widely adopted measure of an ‘ecological worldview’ that uses a Likert-type scale containing fifteen questions related to environmental concern [28]. This framework has been used to investigate the relationship between climate change concern and shifts in individual and collective behaviour as whilst some individuals may become paralysed by their feelings, others are galvanised into action, and modify their behaviour accordingly [29]. These may include changes to ‘everyday’ behaviours such as recycling, diet, or consumption patterns, but potentially could influence behaviours of even greater magnitude, such as reproductive decisions.

1.3 Reproductive decision-making Reproductive decision-making “involves decisions about parenthood (whether and when to be a parent, and the number and spacing of children one wishes to have), including decisions around contraceptive usage and fertility” [30] [p.2]. These decisions are often multi-factorial, in flux, and consequently made over time [31]. The T-D-I-B model is a theoretical framework of reproductive decision-making, breaking down the process into a five-step psychological sequence [32, 33] (Fig 2). These discrete steps are, however, often incorrectly used interchangeably in analyses of environmental concern and reproductive decision-making, particularly with ‘desire’ and ‘intention’. Whilst both terms describe psychological states, desires represent what someone hopes or wishes for, whilst intentions represent desires evaluated with respect to what is achievable in reality [32]. PPT PowerPoint slide

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TIFF original image Download: Fig 2. A model of reproductive decision-making combining the T-D-I-B model with climate change concerns. Note. Adapted from: Miller [32, 33]. The dashed line represents the possibility of climate change-related concern acting as an intervening variable, mediating the transition between traits and desires, and desires and intentions respectively. https://doi.org/10.1371/journal.pclm.0000236.g002 Over the last half-century, changes in childbearing patterns, most noticeably observed in the Global North, have seen a greater proportion of adults now choosing to abstain from parenthood and remain voluntarily childfree [34]. These demographic shifts have been linked to macro-level social changes such as the 1970s feminist movement that expanded women’s reproductive rights, as well as individual-level decision-making, with many citing freedom from childcare responsibility, and maintaining close relationships with their partner as determinants of their decision to remain childfree [35]. These decisions are inherently shaped by normative pressures and structural constraints that are culturally dependent, and variation both within and between Global North and Global South contexts is therefore likely. The term ‘childfree’ is isolated as a distinct concept from ‘childless’, where the former refers to the ability to have children but choosing not to as a result of sociocultural shifts in societal norms, whilst the latter simply refers to an inability to reproduce despite wishing to have children [31]. This dichotomy is problematised as many describe feeling forced into the decision due to their climate change concerns which does not resonate with the typically voluntary nature of choosing to remain childfree [36]. This subset of individuals will therefore be referred to using more specific nomenclature, ‘environmentally childfree’, defined as “not hav[ing] children or restrict[ing] reproduction… partly or fully out of environmental concerns” [37] [p.201]. 1.3.1 Reproductive decision-making in response to climate change. Opposing theoretical stances exist that posit the causal relationship between climate change and childbearing decisions. Demand theories of fertility propose that a better quality of immediate environment is conducive to larger populations due to an abundance of natural resources [38]. This is reversed if the environment deteriorates, as in the case of climate change, where limited availability of resources means that some people may opt to control and limit their reproduction. However, critiques of this position propose a decline in agricultural productivity will lead people to increase their crop cultivation to fulfil their subsistence needs [39]. Consequently, families may decide to have more children to have a larger labour force, leading to a ‘vicious circle’ that will further exacerbate the existing pressures that climate change imposes on the environment [38]. Whilst the direction of the links between climate change and reproductive decision-making is contested, less academic attention has been paid to the role of mental health and wellbeing in shaping these decisions.

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[1] Url: https://journals.plos.org/climate/article?id=10.1371/journal.pclm.0000236

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