Correspondence
2 Lee R. Mortality forecasts and linear life
expectancy trends. In: Bengtsson T, Keilman N,
eds. Old and new perspectives on mortality
forecasting. Demographic research
monographs (a series of the Max Planck
Institute for Demographic Research).
Dordrecht: Springer, 2019: 167–83.
New population forecasts by
Stein Vollset and colleagues1 predict
lower global population growth than
do other forecasts—for instance, the
one published by the UN.2 Vollset
and colleagues assume relatively low
fertility in the future compared with
UN and other forecasts, which leads to
low population growth.
I believe that fertility is not
adequately modelled in the new
forecasts. Vollset and colleagues
assume that the educational level
of women is an important driver for
future fertility levels. Indeed, highly
educated women tend to have fewer
children than do women with little
or no education, both in low-income
and high-income countries. However,
not only does education affect
fertility but also the reverse is true:
fertility influences school attendance.
Adolescent girls and young women
(ie, aged approximately 15–25 years)
with one or more children have
fewer opportunities to attend school
than do women without children,
as shown by studies in Bangladesh,
Malawi, and Zambia,3 Norway,4 and
Denmark.5
A model that includes a two-way
association between fertility and
education will predict higher fertility
levels in countries where women have
little education, compared with the
model that was used by Vollset and
colleagues. Little schooling leads to
high fertility, which, in turn, causes
decreased education. At the same
time, fertility levels will be lower
in countries where women have a
lot of schooling when the two-way
association is modelled compared with
the unidirectional model of Vollset
and colleagues. I suspect that the new
forecasts predict too few births in low-
income countries and particularly in
sub-Saharan African countries.
www.thelancet.com Vol 398 August 14, 2021
I declare no competing interests.
Nico Keilman
nico.keilman@econ.uio.no
Department of Economics, University of Oslo,
N 0951 Oslo, Norway
1 Vollset SE, Goren E, Yuan C-W, et al. Fertility,
mortality, migration, and population scenarios
for 195 countries and territories from
2017 to 2100: a forecasting analysis for the
Global Burden of Disease Study. Lancet 2020;
396: 1285–306.
2 UN Department of Economic and Social
Affairs Population Division. World
population prospects 2019, vol I:
comprehensive tables. New York, NY:
United Nations, 2019.
3 Psaki SR, Soler-Hampejsek E, Saha J,
Mensch BS, Amin S. The effect of adolescent
childbearing on literacy and numeracy in
Bangladesh, Malawi, and Zambia. Demography
2019; 56: 1899–929.
4 Cohen JE, Kravdal Ø, Keilman N. Childbearing
impeded education more than education
impeded childbearing among Norwegian
women. Proc Natl Acad Sci U S A 2011;
108: 11830–35.
5 Gerster M, Ejrnæs M, Keiding N. The causal
effect of educational attainment on completed
fertility for a cohort of Danish women:
does feedback play a role? Stat Biosci 2014;
6: 204–22.
Authors’ reply
We appreciate the opportunity to
respond to comments regarding our
Article.1
Nanna Maaløe and colleagues
suggest that we should use child
survival as a covariate in our fertility
model. The hypothesis that child
mortality is a predictor of fertility
rates has been debated in the field of
demography for some time. Although
there is evidence that a relationship
exists between child mortality and
fertility rates, the causal pattern
between these two measures is
not well established.2 We modelled
fertility with female educational
attainment and contraceptive met
need as covariates. These covariates
are well established as major
predictors of fertility,3 and together
they explained a large proportion of
the past variance in fertility. When
we added survival rates for children
younger than 5 years to the model,
the explained variance increased
modestly, from 80·5% to 83·1%.
We appreciate the feedback and will
continue to improve our fertility
model in future iterations. We are,
however, reluctant to base policy
scenarios on covariates with an
uncertain foundation for a causal
effect.
Jane N O’Sullivan is critical of our
projections and claims that we are
undermining population control
policies and women’s reproductive
rights. We do not agree. We explicitly
stated how important it is to protect
women’s reproductive rights in our
Article. Pretending that decreases in
fertility do not exist does not solve
the problem of overpopulation. As
an example of where our estimates
fail, she points to the acceleration of
fertility decline that our estimates
show from around 2006. Her
claim that our fertility trend for
sub-Saharan Africa deviated from the
estimates from the UN is incorrect.
UN 4 estimates showed a similar
slope to ours, and the UN values are
closer to ours than those from the
Population Reference Bureau. We
have redrawn O’Sullivan’s figure from
the appendix with the addition of the
2019 estimates from the UN World
Pascal Deloche/Godong/Universal Images Group/
Population Prospects (appendix).
Furthermore, O’Sullivan finds
our calculation of countries’ gross
domestic product (GDP) from
forecasts of GDP per worker and
future working-age populations
Getty Images
concerning. Our approach is based
on out-of-sample predictive validity
evidence that GDP is more accurately For more on the Population
estimated from growth rates for Reference Bureau datasheets
see https://www.prb.org/
GDP per worker than from GDP per datasheets
capita.5 We are aware that limitations See Online for appendix
with this approach include the
potential for future compensatory
mechanisms to protect GDP under
declining working-age populations: for
example, increasing female workforce
participation, delaying retirement,
and increasing automation of major
economic sectors.
Stuart Gietel-Basten and
Tomas Sobotka are concerned that
our models, data, and underlying
assumptions have not received
enough scrutiny. As with the Global
581
 Correspondence

Burden of Diseases, Injuries, and
Risk Factors Study, our approach is
a systematic scientific effort that
attempts to include all relevant
Zambia.10–12 Our current framework
and data do not allow for assessing
this hypothesis. We appreciate
the comment, however, and will
12 Psaki SR, Soler-Hampejsek E, Saha J,
Mensch BS, Amin S. The effects of adolescent
childbearing on literacy and numeracy in
Bangladesh, Malawi, and Zambia. Demography
2019; 56: 1899–929.

available data. The data and models
are transparent, peer-reviewed, and
follow the Guidelines for Accurate
and Transparent Health Estimates
Reporting.6
They also claim that our fertility
model is based on uncertain future
pathways. Of course, all long-term
predictions are, but education
trajec­t ories are well determined
because educational attainment is
known after age 25 years. Further,
they claim that our models are
simplistic. There might be nuances
to cultural decisions about having
children, but our fertility model with
female educational attainment and
contraceptive met need explains
80·5% of past variation in fertility.
The UN model, by contrast, uses only
time as a determinant of women’s
reproductive choice.
Finally, Gietel-Basten and Sobotka
claim that our mortality forecasts
are overly pessimistic. Mortality has
almost no effect on population, and
in fact, a slow down or stagnation
Published Online in life-expectancy growth have
August 5, 2021 been observed in many countries
https://doi.org/10.1016/
S0140-6736(21)01746-3 in the past decade. 7–9 Given the
obesity epidemic and other adverse
trends in risk factors, we might, in
many instances, have been overly
optimistic in our forecasts of
mortality.
Nico Keilman suggests that we
are underestimating fertility in sub-
Saharan Africa. His argument is
that the causal pathway between
education and fertility is bidirectional
and should be modelled as such
to avoid bias, possibly in the
opposite direction in settings with
high and low education among
women. The hypothesis is based on
studies of education and fertility
in birth cohorts of Norwegian
and Danish women, plus a study
on the effect of childbearing on
literacy in Bangladesh, Malawi, and
consider it in future iterations of our
population forecasts.
We declare no competing interests. This project was
funded by the Bill & Melinda Gates Foundation.
The funder had no role in the development of this
Correspondence.
Stein Emil Vollset, Amanda E Smith,
Catherine Bisignano,
*Christopher J L Murray
cjlm@uw.edu
Institute for Health Metrics and Evaluation,
University of Washington, Seattle, WA 98195, USA
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for 195 countries and territories from
2017 to 2100: a forecasting analysis for the
Global Burden of Disease Study. Lancet 2020;
396: 1285–306.
2 Doepke M. Child mortality and fertility decline:
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3 Götmark F, Andersson M. Human fertility in
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4 UN Department of Economic and Social
Affairs Population Division. World
population prospects 2019, vol I:
comprehensive tables. New York, NY:
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Spelling errors have been corrected. These
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6: 204–22.

582 www.thelancet.com Vol 398 August 14, 2021