Reducing unmet need and unwanted childbearing: evidence from a panel survey in Pakistan.

Reducing Unmet Need and Unwanted Childbearing: Evidence from a Panel Survey in Pakistan Anrudh K. Jain, Arshad Mahmood, Zeba A. Sathar, and Irfan Masood

Pakistan’s high unmet need for contraception and low contraceptive prevalence remain a challenge, especially in light of the country’s expected contribution to the FP2020 goal of expanding family planning services to an additional 120 million women with unmet need. Analysis of panel data from 14 Pakistani districts suggests that efforts to reduce unmet need should also focus on empowering women who are currently practicing contraception to achieve their own reproductive intentions through continuation of contraceptive use of any method. Providing women with better quality of care and encouraging method switching would bridge the gap that exists when women are between methods and thus would reduce unwanted births. This finding is generalizable to other countries that, like Pakistan, are highly dependent on short-acting modern and traditional methods. The approach of preventing attrition among current contraceptive users would be at least as effective as persuading nonusers to adopt a method for the first time. (Studies in Family Planning 2014 45[2]: 277–299)

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akistan’s high unmet need for contraception, estimated to affect the lives of 7.5 million women, and its low contraceptive prevalence constitute challenges for the country’s policymakers and program managers. Proven models for reducing unmet need for contraception recently received heightened attention globally after the effort was launched at the 2012 London Summit on Family Planning to meet unmet need for 120 million additional women and girls by the year 2020. Refreshingly, this family planning initiative explicitly incorporates women’s and girls’ reproductive intentions rather than stating the goal only in terms of indicators, such as couple years of protection (CYP). The ultimate goal of reducing unmet need, however, is or should be to reduce and ultimately eliminate unintended and unwanted births. From this perspective, we propose that in addition to addressing unmet need, programs should simultaneously help women whose contraceptive need is classified as “met” achieve their reproductive goals. This strategy will help women who have met need and women who will begin practicing contraception in the future to reduce, and ultimately eliminate, their subsequent contribution to overall unwanted fertility. Women using permanent methods at the beginning of this study’s observation period will not contribute to either unmet need or unwanted fertility. Women using reversible methods Anrudh K. Jain is Distinguished Scholar, Population Council, One Dag Hammarskjold Plaza, New York, NY 10017. Email: [email protected]. Arshad Mahmood was (at the time this study was conducted) Director of Monitoring and Evaluation of the FALAH project, Zeba A. Sathar is Country Director and Senior Program Associate, and Irfan Masood is Data Analyst, Population Council, Islamabad, Pakistan. 277

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who had met need at the beginning of this study’s observation period will, however, contribute subsequently to (a) unmet need as a result of contraceptive discontinuation, (b) unwanted fertility as a consequence of contraceptive method failure, and (c) pregnancies as a result of method discontinuation. Some women will become pregnant while using a method and some will discontinue a method and become pregnant before they have a chance to adopt an alternative one. Some women who discontinue using their original method will remain nonusers, will be exposed to the risk of unintended pregnancy, and will be categorized as having an unmet need at a later date.1 Several prior studies have documented these transitions based on retrospective information collected in the DHS contraceptive calendar, including variations in method-specific failure and discontinuation rates. These studies drew attention to the high failure and discontinuation rates associated with traditional and short-acting modern methods in several countries (Blanc, Curtis, and Croft 2002; Bradley, Schwandt, and Khan 2009; Bradley, Croft, and Rutstein 2011; Curtis, Evens, and Sambisa 2011; Ali, Cleland, and Shah 2012). Drawing upon data from 17 countries, Ali, Cleland, and Shah (2012) showed that (a) the number of women who became pregnant within three months of method discontinuation ranged from 3 percent in Peru to 20 percent in the Dominican Republic, (b) the number of women who switched to a reversible modern method ranged from 10 percent in Malawi to 62 percent in Indonesia, and (c) the number of women who remained at risk of a pregnancy following the discontinuation of their original method ranged from 12 percent in Vietnam to 73 percent in Malawi. Curtis, Evens, and Sambisa (2011) documented country-specific variations in the distribution of unintended pregnancies following contraceptive use, its discontinuation, and the nonuse of family planning methods. Jain and colleagues (2013), drawing upon DHS data from 34 countries, found that previous contraceptive discontinuation has already contributed millions of cases to current unmet need, and that contraceptive discontinuation among current users will result in millions of future cases of unmet need. Based on these analyses of cross-sectional data, a conclusion can be drawn that women with met need at the beginning of the observation period will contribute subsequently to both unmet need and unwanted fertility. In this article, we use data from a panel study to estimate the contribution of women with met need at the beginning of the observation period to subsequent unmet need and unwanted fertility in Pakistan.

RELATIONSHIP BETWEEN UNMET NEED AND SUBSEQUENT FERTILITY The concept of unmet need was originally developed to estimate the need for family planning and has been used as an advocacy tool henceforth to demonstrate the need for investment of public resources in organized family planning programs. The concept has been modified over time to improve the accuracy of these estimates. The magnitude of unmet need is typically estimated from cross-sectional surveys. Women’s unmet need status can change over time, however, because of changes in women’s desire to regulate their fertility and/or changes 1 Some women who discontinue using their original method will have no further need for contraception because of wanting more children, or becoming subfecund, or reaching menopause.

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in their contraceptive use. These potential changes raise the issues of stability and predictive validity of unmet need. These issues can only be addressed adequately by analyzing data from longitudinal or panel surveys in which the same women are interviewed more than once. Earlier panel studies from Taiwan showed that women’s stated desire to regulate fertility at the beginning of the observation period was a good predictor of subsequent fertility (Freedman, Hermalin, and Chang 1975; Hermalin et al. 1979). A few additional panel studies have been conducted in recent times in a variety of settings: Morocco (Westoff and Bankole 1998), Peru (Jain 1999), Egypt (Casterline, El-Zanaty, and El-Zeini 2003), India (Roy et al. 2008), and Ghana (Kodzi, Casterline, and Aglobitse 2010). These studies have shown that women’s stated desire to regulate fertility remains stable over time and that women’s stated fertility desire is a good predictor of subsequent fertility. The programmatic implications of the relationship between unmet need and unintended and unwanted fertility, however, have been contradictory. The Peruvian panel study suggested that the goal of reducing overall unwanted fertility would be more effectively achieved through focusing on eliminating unwanted childbearing among those whose contraceptive need is met at one particular point than through focusing on eliminating unmet need (Jain 1999). The Egyptian study, on the other hand, arrived at a different programmatic implication and recommended a continued focus on eliminating unmet need (Casterline, El-Zanaty, and ElZeini 2003). The Peruvian study used a prospective measure of unwanted fertility, whereas the Egyptian study used a retrospective measure. In addition, the difference between the results of the two studies could be attributed in part to lower levels of current and past contraceptive use and the use of more effective methods in Egypt compared with Peru (Casterline, El-Zanaty, and El-Zeini 2003). Bradley, Croft, and Rutstein (2011) used retrospective DHS calendar data to simulate the effect of method failure on unintended births in 20 countries, and concluded that this effect can be reduced substantially if women shift from a less effective to a more effective method. This effect, however, varied by country depending upon the level of contraceptive use and method mix. Given the programmatic importance of these results, addressing this contradictory finding with another set of data from a panel survey is vital. Our article contributes to this literature through an analysis of panel data from Pakistan. Our objectives are: (1) to assess the extent to which contraceptive need for limiting childbearing remains stable or diminishes over time as a result of interventions implemented to remove obstacles to contraceptive use, (2) to assess the extent to which contraceptive need is valid in predicting subsequent fertility, including the level of unwanted childbearing, and (3) to compare the potential reduction in overall unwanted fertility under two hypothetical scenarios—elimination of unmet need and elimination of unwanted fertility among those with met need for contraception.

CONTEXT Pakistan is characterized by low contraceptive use, high contraceptive discontinuation, great unmet need, and high rates of unwanted fertility. Although contraceptive use increased from 12 percent in 1990–91 to 30 percent in 2006–07, and unmet need for family planning decreased from 31 percent to 25 percent during this period (Bradley et al. 2012), contraceptive use remains low and unmet need remains high. Pakistan also has high contraceptive disconJune 2014


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tinuation rates, resulting in particular from the side effects associated with modern contraceptives. About half of currently married women reported in 2007 that they had ever practiced contraception, compared with 30 percent who reported currently practicing contraception in 2007 (NIPS 2008). This means that about 20 percent of currently married women started to practice contraception but discontinued its use by 2007 (NIPS 2008). Factors associated with unmet need range from fear of side effects of modern contraceptives, lack of access and supplies, and husband’s perceived disapproval (Casterline, Sathar, and Hague 2001). High rates of unsafe induced abortion have been closely associated with ineffective, discontinued, and intermittent use of contraceptives and the determination to avoid an unwanted child (Casterline, Singh, and Sathar 2004). In 2008, the Population Council implemented the Family Advancement for Life and Health (FALAH) project in Pakistan to reinvigorate the concept of birth spacing and to improve access to quality family planning services. The FALAH project was first implemented in 20 Pakistani districts, and was extended to 6 additional districts in 2009. The project’s full package of interventions included behavior change communication and measures to strengthen the health system. Behavior change communication interventions included a campaign called “Health Timing and Spacing of Pregnancy” conducted through mass media, community media, and interpersonal communication. Health system interventions invested in the capacity building of managers and providers to promote improved delivery of family planning services through the public health sector. During community mobilization, women and men were told about nearby health facilities that provided family planning services (Mahmood 2012). Two sets of surveys assessed the effect of these interventions on contraceptive use and other indicators. The baseline survey was conducted in 2008–09 in all 26 FALAH districts. The endline survey was conducted in 2011–12 in the 14 districts where the project was able to implement its full set of interventions. Implementing the full set of interventions was not possible in the remaining 12 districts largely because of an earlier closeout of the project and for security reasons. Of the 14 districts, 4 were selected from Khyber Pakhtunkhwa province (Charsadda, Mansehra, Mardan, and Swabi), 4 from Punjab (Bhawalpur, Dera Ghazi Khan, Jhelum, and Rajanpur), and 6 from Sindh (Dadu, Ghotki, Larkana, Sanghar, Sukkur, and Thatta) (Mahmood 2012). In 2008–09, contraceptive prevalence was slightly lower in the FALAH districts than the national average reported in the 2006–07 Pakistan Demographic and Health Survey (PDHS) (28 percent versus 30 percent), but unmet need in the FALAH districts was recorded as much higher (38 percent versus 25 percent). With the possible exception of Jhelum, the districts selected for the project were chosen on the basis of their primarily rural nature and their anticipated high unmet need. Contraceptive use in the FALAH districts increased to about 34 percent and unmet need declined to 34 percent after the interventions were implemented in 2011–12. Consequently, the proportion of demand met in these districts increased from 43 percent in 2008–09 to 50 percent in 2011–12, which was very close to the national average of 54 percent observed in the 2006–07 PDHS. Project interventions helped increase contraceptive use and decrease unmet need for family planning. While FALAH districts were relatively disadvantaged before the initiation of the interventions, they came close to the national averages by the end of the project. The effect of specific interventions on contraceptive use has also been documented by Mahmood Studies in Family Planning 45(2)

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(2012). For example, the rise in contraceptive use in rural areas varied from 3 percent in the Larkana district to 16 percent in the Sukkur district. The district-level variation in increase in contraceptive prevalence was found to be positively associated with an index of public-sector service improvements (Mahmood 2012).2 The variation was also found to be associated with exposure to many of the communications interventions, particularly women and men’s group meetings used for interpersonal communication to improve knowledge and increase discussion regarding contraceptive use and availability of services. In this context, this article will directly contribute to the active policy dialogue regarding priorities and strategies required to address the challenges of unmet need and unwanted childbearing in Pakistan and elsewhere.

DATA AND METHODS This study analyzes panel data drawn from interviews with 5,300 women in 2008–09 and 2011–12 in 14 FALAH districts in Pakistan. Although these districts do not constitute a representative sample of all Pakistani districts, they do represent three different provinces: Khyber Pakhtunkhwa, Punjab, and Sindh. Households in these districts were visited in the baseline survey in three phases3 between February 2008 and November 2009 and were revisited between December 2011 and February 2012 in the endline survey. Women included in both surveys formed the panel for this study. The women were selected by matching the names of respondents and their husbands with the household roster. The woman’s age could not be used for matching because of the lack of robust information and because of reporting discrepancies. We used women’s reports about future desire for having children, current use of contraceptive methods (traditional and modern), current pregnancy status, number of births during the intervening period, and whether the last pregnancy/birth was wanted then, later, or never.

Measurement of Unmet Need We categorized the women in both surveys according to their need for contraceptives to limit births: women with unmet need, women with met need, and women with no need for limiting. Women pregnant at the time of the interview or postpartum amenorrheic for less than 24 months were classified as having unmet need for limiting if they reported that they never wanted their last pregnancy/birth. Women who said they wanted their last pregnancy/birth later, or wanted it at that time, or for whom information was missing were classified as having no contraceptive need for limiting. Women with met need included those who were using either a traditional or modern method at each interview. Women who were practicing contraception to delay their next pregnancy or had an unmet need for spacing were classified as having no contraceptive need for limiting. Thus, women with no need for contraceptives to be used for limiting births included four subgroups: those having unmet need for spacing, those practicing contraception for spacing, those wanting more children soon, and those who are infecund. 2 The index is based on the proportion of FALAH-trained providers, the proportion of FALAH-trained Lady Health Workers’ coverage, and the proportion of facilities having contraceptives in stock. 3 Nine districts were visited between February and May 2008, three between April and August 2009, and two between September and November 2009.

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Stability of Contraceptive Need over Time The stability of contraceptive need between 2008–09 and 2011–12 is indicated by the experience of women who remained in the same contraceptive need category at both surveys regardless of whether they had a birth between the two surveys. The indicator of stability of contraceptive need is estimated by the percent of such women among all women in the survey.

Measurement of Fertility We ascertained from each woman whether she had conceived a child between the two surveys. Women who were pregnant at the time of the second interview but did not have a birth between surveys (n = 352) were coded as having a birth between surveys. Coding was done this way under the assumption that most of these pregnancies would culminate in a live birth. For studying the relationship between women’s contraceptive need status in 2008–09 and their subsequent fertility behavior, we assigned all pregnancies between 2008–09 and 2011–12 to the contraceptive need classification at the beginning of the period irrespective of the contraceptive use status at the time of pregnancy. Thus, method failures and pregnancies during the gap between the discontinuation of a method and the adoption of the same or another method (switching failure) are assigned to women having met need in 2008–09. This treatment is similar to the extended use-effectiveness of a method, which is different from and lower than both the use-effectiveness and the theoretical effectiveness of a method. We expect that the level of subsequent fertility among women without need for contraception would be highest and the level among those with met need would be lowest.

Measurement of Unwanted Fertility Next we assessed whether each woman had a wanted or an unwanted birth between the two surveys. Previous studies have found that the prospective classification of births as unwanted produces higher estimates of unwanted fertility because of changes in fertility desires, compared with the retrospective classification (Westoff and Bankole 1998; Casterline, El-Zanaty, and ElZeini 2003; Koenig et al. 2006). At the same time, retrospective classification of births as unwanted is likely to underestimate the level of unwanted fertility because of post-facto rationalization (Bongaarts 1992; Koenig et al. 2006). To measure the effect of these two biases, we assessed the likelihood of the birth being wanted or unwanted prospectively and retrospectively. We also adjusted the prospective classification for potential bias introduced by changes in women’s fertility desires from wanting no more children in 2008–09 to wanting more children in 2011–12. A woman was classified as having an unwanted birth prospectively if at baseline in 2008– 09 she stated that she did not want another child in the future; she was otherwise classified as having a wanted birth (see Figure 1). A woman was classified as having an unwanted birth retrospectively if at endline in 2011–12 she stated that she never wanted to have the last pregnancy/birth; she was otherwise classified as having a wanted birth. The adjusted prospective definition of unwanted birth classified a woman as having an unwanted birth only if at both interviews she stated that she did not want another child in the future; she was otherwise classified as having a wanted birth.4 As such, women who changed their fertility desires from 4 Mistimed births were classified as wanted in all definitions.


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FIGURE 1 Three classifications of unwanted fertility in Pakistan’s FALAH districts, 2008–09 to 2011–12 Baseline (2008–09)

Endline (2011–12)

A. Prospective Reported wanting no more children

Any report

Birth Reported last birth as unwanted

B. Retrospective Any report

Birth C. Adjusted Prospective Reported wanting no more children

Reported wanting no more children

Birth

wanting “no more” to wanting “more” children and who had a birth between the two surveys were also classified as having a wanted birth. The prospective and adjusted prospective assessments of unwanted fertility were straightforward. The retrospective classification of a birth as wanted or unwanted required many steps, however, because the comparable data to estimate all three types of unwanted fertility were available for 3,557 out of 5,304 women. The question at endline about wantedness was not asked separately for each birth between the two surveys and for current pregnancy at endline. Instead, at endline each woman was asked whether her last pregnancy/birth was wanted then, later, or never. This question referred to the current pregnancy for those who were pregnant at endline and to the last (second, third, or fourth) birth for those who were not pregnant at endline but had multiple births between the two surveys. For this reason and to obtain comparable data concerning prospective and retrospective classifications, we excluded 1,747 women: those who were pregnant in 2008–09 (n = 858), or who had multiple births between the two surveys (n = 668), or who were pregnant at the second survey and had a birth between surveys (n = 221). Of the remaining 3,557 women, 2,170 had no births and 1,387 experienced only one birth between surveys (including 131 women who were pregnant at the second survey but experienced no births between surveys). The 1,387 births/pregnancies can be classified retrospectively and prospectively. To assess the effect of selection bias, however, we also estimated prospective and adjusted prospective unwanted fertility for the full sample of 4,446 women who were not pregnant at the baseline survey in 2008–09. The remaining 858 pregnant women June 2014


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were excluded because the question about future childbearing asked at baseline did not apply to them. This analysis of the full sample included all women having births between the two surveys and those who did not experience birth but were pregnant at endline. The adjusted prospective classification of unwanted fertility is likely to produce the best estimate of unwanted fertility because it is neither affected by post-facto rationalization nor by changes in women’s fertility desires from wanting no more in 2008–09 to wanting more in 2011–12. The difference between prospective and retrospective unwanted fertility can be decomposed into two components: overestimation of the prospective estimate of unwanted fertility attributable to changes in fertility desires, and underestimation of the retrospective estimate of unwanted fertility attributable to post-facto rationalization. The first component is estimated by the difference between the prospective and adjusted prospective estimates of unwanted fertility, and the second by the difference between adjusted prospective and retrospective estimates of unwanted fertility. We used bivariate analysis to study the relationships between any two variables of interest. We also estimated overall unwanted fertility under two hypothetical scenarios: that unmet need is eliminated and that unwanted fertility among those having met need is eliminated (see Appendix for details). All analyses were conducted using IBM SPSS Statistics 20.

RESULTS The period estimates of contraceptive need status for limiting childbearing, shown in Table 1, indicate that unmet need for limiting increased slightly from 22 percent in 2008–09 to 24 percent in 2011–12. Lack of need for limiting decreased from 56 percent to 46 percent between the two surveys, and met need for limiting increased from 22 percent to 30 percent—a full 8 percentage point increase during a short period of about three years.5 TABLE 1 Percentage of women included in panel survey, by need for limiting childbearing, Pakistan’s FALAH districts, 2008–09 and 2011–12 Need for limiting births Unmet need Met need (practicing contraception) Using traditional method Using modern method No need Unmet need for spacing Practicing contraception for spacing Want more children soon Infecund Total Weighted N

Baseline Endline (2008–09) (2011–12) 22.3 24.3 21.5 29.9 4.7 7.1 16.8 22.8 55.6 45.8 15.4 11.1 7.3 7.4 30.0 21.0 3.4 5.6 100.0 100.0 (5,305) (5,305)

5 Further analysis of the method mix (not shown) indicated that 26 percent of women with met need were using traditional methods for limiting in 2008–09, 42 percent were using short-acting reversible modern methods (condoms, injectables, pills), and 32 percent were using long-acting or permanent methods (female sterilization, IUDs). By 2011–12, this method mix had changed slightly: 29 percent were using traditional methods, 35 percent were using short-acting reversible modern methods, and 36 percent were using long-acting and permanent methods.


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Stability of Contraceptive Need Status As discussed below, for the majority of women included in this panel survey, contraceptive need status and its two main components—desire for future childbearing and contraceptive use—remained stable over time. The degree of stability varied, however. Fertility desires were most stable, followed by contraceptive use and contraceptive need status. The degree of stability of contraceptive use and contraceptive need statuses in the context of rapidly rising contraceptive use will, however, be lower than the level observed in this study. Whether women wanted another child in the future remained stable among about 80 percent of women included in this panel survey (35.7 percent + 44.5 percent) (see Table 2). Another 16 percent of all women changed their fertility desire from wanting more children in 2008–09 to wanting no children in 2011–12—a logical progression.6 Only 4 percent moved in the unexpected direction, changing their stated desire from wanting no more children in 2008–09 to wanting more children in 2011–12. Whether women were practicing contraception remained the same among about 74 percent of women, whereas 17 percent shifted from nonuse to use and about 9 percent of all women (or 33 percent of users) discontinued the method and shifted from use to nonuse (see Table 3). As shown in Table 4, contraceptive need for limiting childbearing remained stable among 67 percent of the women: 11 percent had unmet need for limiting in both surveys, 16 percent reported practicing contraception for limiting in both surveys, and 40 percent remained in the “no need” category. This means that one-third of all women experienced a change in contraceptive need in the short period of three years, including 7 percent of the full sample from TABLE 2 Percentage of women, by desire for future childbearing in 2008–09, according to desire in 2011–12, Pakistan’s FALAH districts Want more children in future (2008–09) Yes No Total Weighted N

Want more children in future (2011–12) Yes No Total Weighted N 35.7 16.0 51.7 (2,742) 3.8 44.5 48.3 (2,563) 39.5 60.5 100.0 (5,305) (2,094) (3,211) (5,305) —

— = Not applicable.

TABLE 3 Percentage of women, by practice of contraception in 2008–09, according to practice in 2011–12, Pakistan’s FALAH districts Use of any method (2008–09) Using Not using Total Weighted N

Use of any method (2011–12) Using Not using Total Weighted N 20.2 8.5 28.8 (1,525) 17.0 54.3 71.2 (3,778) 37.2 62.8 100.0 (5,303) (1,973) (3,330) (5,303) —

— = Not applicable. NOTE: The total N of 5,303 is 2 fewer than the N in the other tables because data for two women were not available.

6 Further analysis (not shown) revealed that the 16 percent of all women who changed their fertility desire from wanting more children to wanting no more consisted of 3 percent of all women who had no births between surveys and 13 percent who had at least one birth between surveys. Change in fertility desire for these 13 percent was consistent with their interim fertility behavior. This means that among approximately 93 percent of all women, fertility desires were reported as remaining stable or changes were consistent with interim fertility behavior.

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TABLE 4 Percentage of women, by need for contraceptives for limiting childbearing in 2008– 09, according to need in 2011–12, Pakistan’s FALAH districts Need for contraceptives for limiting births (2008–09) Unmet need Met need No need Total Weighted N — = Not applicable.

Need for contraceptives for limiting births (2011–12) Unmet need Met need No need Total Weighted N 11.1 7.3 4.0 22.3a (1,183) 3.7 15.7 2.1 21.5 (1,142) 9.6 6.9 39.7 56.2 (2,980) 24.4 29.8a 45.8 100.0 (5,305) (1,292) (1,583) (2,430) (5,305) —

aValue differs from sum because of rounding.

unmet to met need and 4 percent from met to unmet need for limiting. Shifts out of the no contraceptive need category were substantial: 10 percent shifted from no need to unmet need for limiting and 7 percent shifted to met need status. The no need category in 2011–12 gained 4 percent from unmet need and 2 percent from met need groups in 2008–09.7

Predictive Validity of Contraceptive Need Table 5 presents results for the 3,557 women for whom comparable data were available to estimate all three types of unwanted fertility. Thirty-nine percent of these women experienced a birth between surveys. This included 15 percent having an unwanted birth and 24 percent having a wanted birth. The percentage of women having an unwanted birth decreased to 14 percent after making adjustments for changes in fertility desire, and to 8 percent according to the retrospective definition. The predictive validity of the contraceptive need concept can be assessed by considering all births or only unwanted births between the two surveys. Results shown in Table 5 suggest that TABLE 5 Percentage of women not pregnant in 2008–09 having one unwanted birth between the two surveys, by need for contraceptives for limiting childbearing in 2008–09, Pakistan’s FALAH districts Women Percentage of women having one having unwanted birth between two surveys one birth Need for contraceptives for between Adjusted limiting births in 2008–09 surveys Prospective Retrospective prospective Unmet need for limiting 38.6 38.6 16.9 34.0 Met need 18.3 18.3 8.0 16.6 Using modern method 16.3 16.3 6.7 14.9 Using traditional method 25.6 25.6 12.8 22.9 No need 53.5 0.0 3.7 0.0 Unmet need for spacing 75.3 0.0 5.1 0.0 Practicing contraception for spacing 63.5 0.0 8.3 0.0 Want soon 48.2 0.0 2.1 0.0 Infecund 9.6 0.0 0.0 0.0 All women not pregnant in 2008–09 39.0 15.2 8.3 13.6

Weighted number of women having 0–1 births (890) (1,087) (861) (226) (1,580) (393) (283) (727) (173) (3,557)

NOTE: Women who were pregnant at the time of the 2008–09 baseline survey, or had multiple births between surveys, or were pregnant at the 2011–12 endline survey and had only one birth between surveys were excluded.

7 Whereas women who shifted from met need in 2008–09 to unmet need in 2011–12 constituted only 4 percent of all women, they constituted 17 percent of those who were practicing contraception in 2008–09 (not shown). Further analysis revealed that although these women remained interested in limiting future childbearing, they all discontinued contraceptive use sometime between the two surveys. In comparison, the 2 percent who moved from met need to no need did so because of a change in fecundity status or changes in fertility desires (not shown).


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the concept of contraceptive need appears to be valid in predicting subsequent fertility and unwanted fertility. Women having no need for contraceptives to limit births at baseline had higher subsequent fertility than those who had unmet need for limiting, which was higher than those who had their contraceptive need met: about 54 percent of women having no need for limiting had one birth between surveys, compared with 39 percent of those having unmet need and 18 percent of those having met need for family planning. Women who were using traditional methods in 2008–09 experienced higher subsequent fertility than did those using a modern method (26 percent versus 16 percent). The relationship between contraceptive need status and unwanted fertility remained the same irrespective of the definition of wantedness used (see Table 5 and Figure 2). Women having unmet need in 2008–09 had the highest subsequent unwanted fertility and women having no need for contraceptives for limiting had the lowest unwanted fertility. Moreover, unwanted fertility among women using traditional methods in 2008–09 was higher than among women using a modern method.8 These observations confirm the validity of the unmet need concept in predicting subsequent wanted and unwanted fertility.

Relative Estimates of Unwanted Fertility The prospective definition produced a higher estimate of unwanted fertility than the retrospective definition among women having unmet need and women having met need (see Table 5 and Figure 2). The trend is reversed, however, for those who had no need for limiting in 2008–09. This is primarily because some births among those women who wanted their next child soon and among those who were interested in spacing were classified as unwanted retrospectively. 9 FIGURE 2 Percentage of women experiencing unwanted fertility between 2008–09 and 2011–12, by definition of unwanted fertility and need for limiting births in 2008–09, Pakistan’s FALAH districts

Unwanted fertility (percent)

45 40

Unmet need for limiting

38.6 34.0

35 30

Met need

25 20

18.3

16.9

15

8.0

10 5 0

No contraceptive need

16.6

3.7 0.0

Prospective

0.0

Retrospective Definition of unwanted fertility

Adjusted prospective

8 The levels of fertility and unwanted fertility for this reduced sample (shown in Table 5) are lower than those for the full sample (not shown). For example, 51 percent of all women and 13 percent of infecund women in the full sample had one or more births and 17 percent of all women had one or more unwanted births between the two surveys. The corresponding percentages for the reduced sample were 39 percent, 10 percent, and 15 percent. Nevertheless, the relationship between contraceptive need status and subsequent fertility as well as unwanted fertility for the full sample remained the same (not shown). This means that selectivity in using the reduced sample did not introduce any bias in the relationship between contraceptive need status and subsequent fertility. 9 About 10 percent of women who were classified as infecund in 2008–09 had a birth between surveys (see Table 5). All these women were classified as infecund in 2008–09 because they had been married for at least five years before the survey and had no birth during that period. None of them had an unwanted birth according to any of the three definitions.

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FIGURE 3 Estimated contribution of two biases to unwanted fertility, Pakistan’s FALAH districts, 2008–09 to 2011–12

Unwanted fertility (percent)

16

Prospective (15.2)

Change in fertility desire (1.6)

Adjusted prospective (13.6) 12 8

Post-facto rationalization (5.3) Retrospective (8.3)

4 0

Definition of unwanted fertility

The retrospective classification could underestimate the level of unwanted fertility because of post-facto rationalization. At the same time, the prospective classification could overestimate the level of unwanted fertility because some women do change their fertility desires. The adjustment for changes in women’s fertility desires reduced the prospective estimate of unwanted fertility from 15.2 percent to 13.6 percent, which is still higher than the retrospective estimate of 8.3 percent (see Table 5). The discrepancy between the adjusted prospective and the retrospective classification is mainly created by the 18.1 percent of all births (or 251 births) that were classified as wanted retrospectively and unwanted by the adjusted prospective definition. This observed shift from unwanted to wanted status is consistent with the hypothesis of post-facto rationalization. That is, most women are unlikely to report a birth as unwanted after the fact. Women are unlikely to report at both surveys that they do not want more children in the future and then have a wanted child in between.10 For this reason, we believe that the adjusted prospective classification provides a better estimate of unwanted fertility than the retrospective classification. This classification is neither affected by post-facto rationalization nor by changes in fertility desires from wanting no more children in 2008–09 to wanting more in 2011–12. As illustrated in Figure 3, of the 6.9 percentage points difference between the prospective (15.2 percent) and the retrospective (8.3 percent) estimate of unwanted fertility in Pakistan, 1.6 percentage points (15.2–13.6) can be attributed to overestimation of prospective unwanted fertility resulting from change in fertility desires, and 5.3 percentage points (13.6–8.3) to underestimation of retrospective unwanted fertility resulting from post-facto rationalization.

10 The prospective and retrospective classifications are consistent for a large majority (74 percent) of 1,387 births with comparable data: 17 percent were classified as unwanted by both definitions and 57 percent as wanted. These two definitions are inconsistent for the remaining 26 percent of births: 22 percent were classified as wanted retrospectively but unwanted by the prospective definition, and 4 percent were classified as unwanted retrospectively but wanted by the prospective definition. Twenty-two percent of births that were classified as wanted retrospectively but unwanted prospectively consisted of two groups. Four percent of births occurred among women who changed their fertility desires from wanting no more to wanting more children. These births are reclassified as wanted births in the adjusted prospective definition. The remaining 18 percent of births occurred among those women who did not change their fertility desires and reported wanting no more children at both surveys. These births are classified as unwanted in the adjusted prospective definition.


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Potential Unwanted Fertility under Two Hypothetical Scenarios The purpose of reducing unmet need for contraception is to reduce unwanted fertility. Women in 2008–09 are classified into three groups according to their contraceptive need for limiting: having unmet need, having met need, and having no need for contraception to limit births. The contribution of each group to the overall level of unwanted fertility is the product of its relative size and its level of unwanted fertility (see Appendix for further details). The relative size of the group of women having unmet need for contraception estimated from data shown in Table 5 is 0.250 (890 ÷ 3,557). According to the adjusted prospective classification, 34 percent of this 0.250 had an unwanted birth between the two surveys (see Table 5). Thus, the contribution of this group to overall unwanted fertility is 8.5 percent (0.250 × 34.03). Similarly, the contribution of the met need group to overall unwanted fertility can be estimated as 5.1 percent (0.306 × 16.57), and the contribution of the no need group can be estimated to be 0.0 percent (0.444 × 0.0). The sum of the three components equals 13.6 percent (8.5 + 5.1 + 0.0). The overall unwanted fertility can be reduced by either eliminating unmet need for contraception or by ensuring that women having met need have the information and the means to eliminate their subsequent unwanted fertility. The best results, however, can be obtained by pursuing both strategies simultaneously. Hypothetically, overall unwanted fertility could be eliminated completely (reduced from 13.6 to 0.0) if both strategies were to be pursued simultaneously and both were completely successful. If a choice has to be made, however, which strategy would produce lower unwanted fertility? Whereas the contribution of women having unmet need to overall unwanted fertility (8.5 percent) exceeds that of women having met need (5.1 percent), the choice between the two strategies is not straightforward, because elimination of unmet need would not completely eliminate unwanted fertility. To illustrate this point, we estimate the overall unwanted fertility under two hypothetical scenarios: (1) unmet need for contraception is eliminated, and (2) unwanted fertility among women having met need is eliminated. These effects are estimated under the assumption that no new method is added that would change the method mix, the average discontinuation rate, or the average unwanted fertility rate among users. No attempt is made to assess the feasibility of achieving the goals stated by these hypothetical scenarios. Under the first scenario, the elimination of unmet need for contraception would not eliminate unwanted fertility, because of contraceptive failure and pregnancies following contraceptive discontinuation. This means that elimination of unmet need would not reduce the overall unwanted fertility by a full 8.5 percentage points—the current contribution of this group. Instead, the contraceptive and fertility behavior of women in the unmet need group would be more likely to mimic the behavior of women who are practicing contraception and are in the met need group. This means that as the contraceptive need among those who currently have an unmet need is met, their level of unwanted fertility would be reduced from its current level of 34.0 percent to 16.6 percent—the current level of unwanted fertility among women having met need. The effect of eliminating unmet need would then be to reduce their contribution to overall unwanted fertility from 8.5 percent to 4.1 percent (0.250 × 16.57). Thus, the effect of eliminating unmet need for contraception on overall unwanted fertility would not be to reduce the overall unwanted fertility by a full 8.5 percentage points, but by 4.4 percentage points (8.5 – 4.1), or from 13.6 percent to 9.2 percent. June 2014


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TABLE 6 Percentage of women who had an unwanted birth between the two surveys and percentage expected to have an unwanted birth under two hypothetical scenarios, Pakistan’s FALAH districts, 2008–09 and 2011–12 Women with an unwanted birth Adjusted Prospective prospective Retrospective Classification of All Reduced All Reduced All Reduced a a unwanted fertility women a sample b women sample b women sample b Observed 16.6 15.2 15.0 13.6 — 8.3 Implied Unmet need for limiting fully satisfied 10.8 10.1 9.9 9.2 — 6.1 Unwanted births among women with met need eliminated 10.9 9.7 9.6 8.5 — 5.9 Weighted N (4,446) (3,557) (4,446) (3,557) (3,557) — = Not applicable. a Excludes women who were pregnant in 2008–09. b Excludes women who were pregnant in 2008–09, or who had multiple births between surveys, or who were pregnant in 2011–12 and had only one birth between surveys.

Under the second scenario, as women having met need succeed in eliminating their subsequent unwanted fertility through sustained and effective contraceptive practice, their contribution to overall unwanted fertility would be reduced from 5.1 percent to zero. Although unwanted fertility among women having met need cannot be eliminated completely in the absence of access to safe abortion services, considerable progress can be made by improving the effectiveness and continuation of the method used, and by reducing or eliminating the gap between discontinuation of the original method and adoption of the same or another method. Under this scenario, the effect of eliminating unwanted fertility among those having met need would be to reduce the overall unwanted fertility by 5.1 percentage points, from 13.6 percent to 8.5 percent. The comparison of these two scenarios suggests that whereas the difference between the effects of these two strategies pursued separately on implied unwanted fertility would be less than one percentage point (0.7 percent), the second strategy of eliminating unwanted fertility among women having met need would have a slight edge in Pakistan. Table 6 shows the results of similar simulations for other groups: prospective and adjusted prospective classifications of unwanted births for all women and for a reduced sample, and for retrospective classifications of births in the reduced sample. The difference between the implied unwanted fertility under the two strategies (shown in rows 2 and 3 of Table 6) remained less than 0.7 percentage points. For practical purposes, we can conclude that either of the two strategies, if pursued alone, would be equally effective in Pakistan.

Comparisons with Other Studies Table 7 compares the results from analysis in Pakistan with similar simulations for panel surveys from Egypt, Morocco, Peru, and Taiwan. The comparison of implied unwanted fertility estimates (shown in the last two rows of Table 7) suggests that elimination of unwanted fertility among those having met need in Morocco and Peru is likely to produce lower overall unwanted fertility than focusing on eliminating unmet need alone (8.4 versus 10.9 for Morocco; 4.8 versus 7.5 for Peru), yet similar comparisons for Egypt and Taiwan suggest a focus on eliminating unmet need in those countries to be a better option (8.0 versus 6.3 for Taiwan; 4.1 versus 3.4 for Egypt). Studies in Family Planning 45(2)

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TABLE 7 Proportion of women, by contraceptive need status at the beginning of the period and, among those, percentage with unwanted fertility, five countries Taiwan Egypt Pakistan Morocco Peru Characteristic 1967–74 1995–97 2008–12 1992–95 1991–94 Contraceptive need status Proportion with unmet need (p1) 0.244 0.177 0.250 0.145 0.182 Proportion with met need (p2) 0.299 0.192 0.306 0.290 0.499 Total demand (p1 + p2) 0.543 0.369 0.556 0.435 0.681 Proportion of demand unmet (p1 ÷ [p1 + p2]) 0.450 0.479 0.450 0.334 0.267 Unwanted fertility Among women with unmet need (r1) 32.7 23.2 34.0 58.0 26.1 Among women with met need (r2) 11.6 9.2 16.6 25.0 11.0 Ratio (r2 ÷ r1) 0.355 0.395 0.487 0.431 0.421 Total unwanted fertilitya Observed unwanted fertility a (R) 11.5 5.9 13.6 15.7 10.2 Proportion of unwanted fertility contributed by those with met need (p2 × r2) ÷ R 0.303 0.301 0.373 0.462 0.536 Implied unwanted fertility when: a Unmet need is eliminated (R1): r1 = r2 6.3 3.4 9.2 10.9 7.5 Met need is eliminated (R2): r2 = 0 8.0 4.1 8.5 8.4 4.8 aExcludes unwanted fertility contributed by women with no contraceptive need: R = p

1 × r1 + p2 × r2.

The experience of these five countries can be used to derive general guidelines that may be applicable to other countries. This can be done by using an algebraic identity comparing implied unwanted fertility under each of the two scenarios, which reduces to a comparison of two ratios: (1) the ratio of unmet need and total demand (p1 ÷ [p1 + p2]) and (2) the ratio of unwanted fertility among women having met and unwanted fertility among those having unmet need (r2 ÷ r1) (see Appendix for details). A focus on eliminating unmet need would be preferable in countries where p1 ÷ (p1 + p2) is greater than r2 ÷ r1, which is the case in Egypt and Taiwan. A focus on eliminating unwanted fertility among those having met need would be preferable in countries where p1 ÷ (p1 + p2) is smaller than r2 ÷ r1, which is the case in Morocco and Peru. Each strategy would imply an equal reduction in unwanted fertility if the two identities are equal, which is nearly the case in Pakistan (see Table 7). Comparing the results from Egypt and Peru, Casterline, El-Zanaty, and El-Zeini (2003) attributed the differences between these countries to a lower level of current and past practice of contraception and the use of more effective contraceptive methods in Egypt compared with Peru. The outcome of the comparisons of the five countries presented in Table 7 appears to support this assertion regarding the practice of more effective contraception; the outcome appears to depend more on the level of unwanted fertility among women having met need11 11 The level of unwanted fertility among women having met need is determined by the method mix among users. For example, unwanted fertility among women having met need will be highest if most of the women were using short-acting reversible methods (condoms, injectables, pills, and traditional methods). Unwanted fertility among users will decrease as the method mix shifts toward long-acting reversible methods (implants, IUDs), and will become close to zero if the method mix shifts completely to permanent methods. The contribution of women with met need to overall unwanted fertility would also decrease as the method mix shifts from short-acting reversible methods to long-acting reversible and permanent methods. For example, the contribution of women having met need to total unwanted fertility decreases from 54 percent in Peru and 46 percent in Morocco to 37 percent in Pakistan and 30 percent in Taiwan and Egypt (Table 7). Thus, one would focus on eliminating unmet need in countries such as India having high use of permanent methods and Egypt and Taiwan having a large proportion of women using IUDs. In countries such as Morocco and Peru that have a method mix less favorable to these methods, a focus on eliminating unwanted fertility among women having met need would be warranted. In 2008–09, about 68 percent of women having met need for limiting in Pakistan were using short-term reversible modern and traditional methods; therefore, each strategy would be equally effective in reducing unwanted fertility in Pakistan (not shown).

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than upon the level of unmet need in a country. For example, unmet need in Pakistan was highest, but the two ratios for Pakistan turned out to be about the same. Unwanted fertility among women having met need was highest in Morocco, which is consistent with the outcome. A comparison of Pakistan with Taiwan and Egypt shows that the outcome seems to be determined by the higher level of unwanted fertility in Pakistan. In addition, the absolute difference between the effects of the two strategies for Pakistan is of the same magnitude as in Egypt (0.7 percentage points). The overall unwanted fertility would decrease from 5.9 percent to 3.4 percent in Egypt and from 13.6 percent to 9.2 percent in Pakistan as women’s unmet need in these countries is eliminated. A further reduction in unwanted fertility even in these countries, however, would require a focus on helping women with met need reduce and ultimately eliminate their subsequent unwanted fertility. As shown in Table 7, 9 percent of women having met need for limiting in Egypt and 17 percent in Pakistan had an unwanted birth. These births resulted from method failures and pregnancies that occurred during the gap between method switching. The contribution of method failure can be reduced by using a method more effectively or by using a more effective method. The contribution of pregnancies during the gap can be reduced by improving the continuity of the same method and by reducing or eliminating the gap between method switching.

CONCLUSION The present analysis, based on a panel survey of about 5,300 women from 14 FALAH districts in Pakistan, revealed that although unmet need for spacing decreased from 15 percent in 2008– 09 to 11 percent in 2011–12, unmet need for limiting childbearing increased slightly from 22 percent to 24 percent but the met need increased by a full 8 percentage points from 22 percent to 30 percent during this short period. Moreover, the unmet need for limiting of about 7 percent of all women in Pakistan’s FALAH districts (or 33 percent of those having unmet need in 2008–09) was met by the endline survey in 2011–12. Clearly, the interventions implemented during the intervening period did increase the met need for contraception in these districts. Three results of the present analysis of panel data from Pakistan are in accordance with previous panel studies. First, a vast majority of women (80 percent) did not change their desire for future childbearing between the two surveys. The level of contraceptive need for limiting also remained stable over time, with about 67 percent of women remaining in the same category of contraceptive need between the two surveys. This proportion is comparable to that observed in other studies. For example, Casterline, El-Zanaty, and El-Zeini (2003) found that 59 percent of women in Egypt did not change their contraceptive need status. Whereas the stated fertility desires are likely to change slowly when improvements in women’s social and economic conditions take place, women’s contraceptive use and contraceptive need statuses are likely to change much faster with improvements in the country’s family planning program. That is, the degree of stability of contraceptive use and contraceptive need statuses observed in this study is likely to decrease much faster with rapidly rising contraceptive use. Second, as observed in prior panel studies, the concept of contraceptive need is found to be valid in predicting both subsequent fertility and unwanted fertility in Pakistan. The highStudies in Family Planning 45(2)

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est proportion of women having at least one birth between surveys was among those with no contraceptive need in 2008–09, followed by those with unmet need for contraception. Women with met need in 2008–09 had the lowest fertility between the two surveys. The level of unwanted fertility among women having unmet need for limiting births was higher than among those with met need, which in turn was higher than among those with no need. Third, like many similar prior studies (Westoff and Bankole 1998; Casterline, El-Zanaty, and El-Zeini 2003; Koenig et al. 2006), the prospective classification produced a higher estimate of unwanted fertility (15.2 percent), compared with the retrospective classification (8.3 percent). The two definitions were consistent for 74 percent of the single births: 17 percent were reported as unwanted and 57 percent were reported as wanted by both definitions. The adjustment for changes in women’s fertility desires reduced the prospective estimate of unwanted fertility from 15.2 percent to 13.6 percent, which was still higher than the retrospective estimate of 8.3 percent. The present analysis has contributed to the literature by decomposing the difference between the prospective and retrospective estimates of unwanted fertility into two components: unwanted fertility attributable to changes in fertility desire and unwanted fertility attributable to post-facto rationalization. In our view, the adjusted prospective classification produced the best estimate of unwanted fertility (13.6 percent) because this classification was neither affected by post-facto rationalization nor by changes in women’s fertility desires from wanting no more children in 2008–09 to wanting more in 2011–12. The difference of 6.9 percentage points between prospective (15.2 percent) and retrospective (8.3 percent) estimates of unwanted fertility in Pakistan can be decomposed into two components: 1.6 percentage points can be attributed to overestimation of prospective unwanted fertility because of changes in fertility desires, and 5.3 percentage points to underestimation of retrospective unwanted fertility because of post-facto rationalization. In other settings, this attribution would depend upon the magnitude of changes in fertility desires. The current programmatic focus of FP2020 and reproductive health and family planning programs is to reach women having unmet need for contraception, which is expected to reduce overall unwanted fertility. We caution against leaving out the current users from the equation, however, which would affect the number of women having or not having unmet need at the end. A recent study of cross-sectional data in 34 countries documented the potential contribution of women with met need to unmet need resulting from contraceptive discontinuation (Jain et al. 2013). The present analysis of panel data in Pakistan confirmed this finding and also showed that women practicing contraception in 2008–09 contributed substantially to unmet need subsequently and also contributed to subsequent unwanted fertility between 2008–09 and 2011–12. About 4 percent of all women or 17 percent of those with met need in 2008–09 were classified as having an unmet need for family planning in 2011–12. In comparison, in Egypt about 20 percent of women who were practicing contraception for limiting in 1995 were classified as having unmet need for limiting in 1997 (Casterline, El-Zanaty, and El-Zeini 2003). A shift from met to unmet need for contraception to limit births could have substantial impact on changes in the level of unmet need estimated from two cross-sectional surveys. For example, whereas met need for limiting in Pakistan increased by 8 percentage points be-

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tween the two surveys, hypothetically it would have increased by another 4 percentage points if women with met need at baseline continued to practice contraception. Similarly, sustained practice of contraception would have decreased unmet need for limiting by 2 percentage points instead of a recorded increase of 2 percentage points. In other words, supporting women with met need in the continuation of use of the same or a different contraceptive method is a useful strategy to reduce unmet need in a country. Women with met need also contributed substantially to overall unwanted fertility. The contributions were 54 percent in Peru, 46 percent in Morocco, 37 percent in Pakistan, and 30 percent in Egypt and Taiwan. The elimination of unwanted fertility among those with met need in Pakistan is likely to bring down overall unwanted fertility from 13.6 percent to 8.5 percent, which would be as effective as persuading nonusers to adopt a method for the first time.

Programmatic Implications The best strategy that family planning programs can use to reduce overall unwanted fertility is to focus on both groups of women: those who have unmet need for contraception and those whose contraceptive need is met. Nevertheless, the present analysis has shown that a focus on empowering women with met need to eliminate their subsequent unwanted fertility would be an effective strategy to reduce overall unwanted fertility, especially in countries with relatively low use of long-acting and permanent methods and fairly high dependence on short-term reversible modern and traditional methods. A focus on supporting women with met need will subsequently reduce both unmet need and unwanted fertility. Such a focus implies that the program follows a woman rather than a specific method. In terms of research, this implies a shift from the exclusive focus on methodspecific analysis of effectiveness and discontinuation to all-segments continuation of (any) contraceptive method (Blanc, Curtis, and Croft 2002), and to estimating the extent to which women are successful in achieving their own stated fertility goals during the period of observation (Jain 2001). Such a focus also makes sense programmatically because women having met need have already overcome the many barriers to accessing family planning services, such as culture, distance, cost, husband’s objection, and fear of side effects. Hence, it would appear easier for programs to strengthen women’s resolve and to equip them with information to reduce unwanted fertility than to reduce these barriers among women with unmet need who may not have used any method at all. The level of unwanted fertility among women with met need in a country depends upon the method mix and switching patterns. Method mix determines the average effectiveness and average discontinuation rate, and switching patterns determine the length of the period (the gap) between discontinuation of the original method and adoption of another method, and, therefore, the number of unwanted births during this gap. The importance of the method mix and switching patterns has been documented by several prior studies based on retrospective DHS calendar data (Blanc, Curtis, and Croft 2002; Bradley, Schwandt, and Khan 2009; Bradley, Croft, and Rutstein 2011; Curtis, Evens, and Sambisa 2011; Ali, Cleland, and Shah 2012). The effect of method failure on unintended births can be reduced substantially by using the same method more effectively or by shifting from a less effective to a more effective method. The magnitude of this reduction potentially achieved from a shift from less effective to more Studies in Family Planning 45(2)

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effective methods varies by country depending upon the level of contraceptive use and method mix (Bradley, Croft, and Rutstein 2011). In addition to pregnancies that result from method failure, a substantial proportion of women become pregnant following discontinuation of their original method and have unintended pregnancies, and many others remain at risk of a pregnancy (Curtis, Evens, and Sambisa 2011; Ali, Cleland, and Shah 2012). The contribution of women having met need at the beginning of the observation period to subsequent unmet need and overall unwanted fertility can therefore be reduced by: using a method more effectively, shifting the method mix toward long-acting reversible and permanent methods within the context of choice, and improving switching among methods (i.e., reducing the gap between discontinuation of a method and adoption of another method). Many programmatic interventions can affect the behavior of women having unmet and met need. For example, expanding the choice of methods by adding methods not available in a country would increase contraceptive prevalence by attracting new contraceptive users and by facilitating method switching. This proposition makes sense intuitively, and strong evidence exists from cross-country analyses (Jain 1989; Ross and Hardee 2013; Ross and Stover 2013). Another cross-country analysis showed that an expansion in the number and composition of methods available in a country is likely to reduce contraceptive discontinuation relevant to unmet need (Jain et al. 2013). The actual effect of method addition would depend, however, upon the extent to which the method is adopted and used once made available in a country. Another approach would be to improve the quality of care provided to clients whenever they come into contact with service providers: at the time of checkup or resupply of a method, or at the time of initial adoption of a method. This would mean first and foremost helping clients initially select a method that is appropriate to their needs and circumstances, and second, providing them with accurate information about the method selected and the importance of reducing and eliminating the gap between methods when switching. Evidence of the benefit resulting from improving quality of care comes from a variety of studies, including simulations and cross-sectional and longitudinal studies. For example, women in Indonesia who received the method of their choice continued to use the method longer than women who did not (Pariani, Heer, and Van Arsdol 1991). Moreover, cross- sectional and longitudinal studies have documented that improvements in quality of care received at initial adoption of a method increase subsequent contraceptive use and reduce unwanted fertility. For example, a longitudinal study in the Philippines measured quality of care received at the time of initial adoption on a 20-point scale and divided women into three groups according to the degree of quality of care received. A follow-up study of these women showed that the quality of care received at initial method adoption was associated with improved continuation from 53 percent to 63 percent and a reduction in subsequent unwanted fertility from 16 percent to 8 percent (Jain et al. 2012). An increase of 10 percentage points in continuation of use is not inconsequential. Another longitudinal study, conducted in Senegal, also showed increased likelihood of contraceptive continuation with improved quality of care received at the initial visit; those who received good care were 1.3 times more likely to be using a method about 18 months later than were those who did not receive good care (Sanogo et al. 2003). A body of literature also exists on how to improve quality of care. For example, the Salutation, Assess, Help, and Reassure model (SAHR) has been demonstrated to be effective in improving client–provider interactions in Pakistan (Sathar et al. 2005). June 2014


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Experimental studies linking improved quality of care and continuity of use failed to show evidence of a substantial effect of the interventions, however, which has led to disappointment and skepticism among researchers about the importance of counseling and quality of care for improving continuity of use and reducing unwanted fertility (Harbison 2005; Cleland et al. 2006). The small effect found in these studies may have been a consequence of the small increase in the magnitude of the effect of the intervention on improved quality of care. Moreover, because quality is a dimension of services, it is not absent in the control areas (Jain et al. 2012). As others have noted, many strategies to reduce contraceptive discontinuation have limitations (Jain et al. 2013). Evidence of the effect of method expansion is based on crosscountry analysis; country-specific evidence is missing from longitudinal and experimental studies and would be needed to document the actual effect of method addition on decreasing the discontinuation rate and unwanted fertility or on increasing average effectiveness and contraceptive use. Evidence regarding the effect of quality of care on contraceptive use and unwanted fertility is available from longitudinal but not from experimental studies. Nevertheless, the need to improve service quality and counseling was stressed by a recent WHO study as a method of reducing high discontinuation rates (Ali, Cleland, and Shah 2012). Expanding contraceptive choice and improving quality of care would still appear to be the best strategies for moving forward. The main implication of the results of the present study is that efforts should be made to reduce the gap between discontinuation of a method and adoption of the same or a different method. This applies to those who are currently using a reversible (modern or traditional) method and those who may start using a method now or in the future. An increased focus on women with met need does not imply that programs should ignore those with unmet need. In fact, a focus on women with met need would also be the best strategy to reduce contributions by those who start practicing contraception now to unmet need and unwanted fertility in the future. This can be accomplished by helping women to close the gap when switching methods. This problem exists not only in developing countries but in developed countries as well. For example, in the United States, attention has recently been drawn to the need to bridge the gap between periods of contraceptive use in order to reduce unintended pregnancies (Lesnewski, Prine, and Ginzburg 2011; Brody 2012). The issue is not simply about adding a method or improving counseling per se, but rather about clients’ needs and right to have a choice among methods available and their right to receive accurate information from service providers and other sources, including mass media. Irrespective of the method initially selected, clients need and deserve accurate information concerning how to correctly use the method selected, what to expect regarding adverse reactions, and how to manage these side effects. Clients must be encouraged to switch the method selected when it becomes unsuitable and must be reassured by the provider that the method can be changed. Informing clients that they can become pregnant during the gap between discontinuation of a method and adoption of another method is vital. Women must be encouraged to protect themselves by reducing this gap.


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APPENDIX Let pi be the proportion of women in the ith contraceptive need status and ri be the unwanted fertility among women in the ith contraceptive need status. The contribution of women in the ith contraceptive need category to the overall unwanted fertility would be pi × ri. The overall unwanted fertility among all women (R) would be equal to ∑ pi × ri. Let contraceptive need status be divided in three categories: unmet need, met need, and no need. These three categories are denoted by i equal to 1, 2, and 3, respectively. We can now estimate values of R under two scenarios. 1. Unmet need is eliminated: Women with unmet need are added to those who already are in the met need category and mimic the unwanted fertility level of those with met need—that is, r1 = r2. Overall unwanted fertility (R1) implied under this scenario would be: R1 = [p1 × r2] + [p2 × r2] + [p3 × r3]. 2. Unwanted fertility among those with met need is eliminated: r2 = 0. Overall unwanted fertility (R2) implied under this scenario would be: R2 = [p1 × r1] + [p3 × r3]. 3. Comparison of implied unwanted fertility: a. Scenario 1 would be preferable if R1 < R2, or ([p1 × r2] + [p2 × r2] + [p3 × r3]) < ([p1 × r1] + [p3 × r3]), or (p1 + p2) × r2 < (p1 × r1), or (p1 ÷ [p1 + p2]) > (r2 ÷ r1). Elimination of unmet need would imply lower unwanted fertility than elimination of unwanted fertility among those with met need if unwanted fertility among those with met need (r2) is relatively low. b. Scenario 2 would be preferable if R1 > R2, or ([p1 × r2] + [p2 × r2] + [p3 × r3]) > ([p1 × r1] + [p3 × r3]), or (p1 + p2) × r2 > (p1 × r1), or (p1 ÷ [p1 + p2]) < (r2 ÷ r1). Elimination of unwanted fertility among those with met need would imply lower unwanted fertility than elimination of unmet need if unwanted fertility among those with met need (r2) is relatively high. c. Both scenarios would imply the same unwanted fertility if R1 = R2, or ([p1 × r2] + [p2 × r2] + [p3 × r3]) = ([p1 × r1] + [p3 × r3]), or (p1 + p2) × r2 = (p1 × r1), or (p1 ÷ [p1 + p2]) = (r2 ÷ r1). Because the value of unwanted fertility among those with met need would depend upon the method mix, elimination of unmet need would be preferable in countries where the method mix is skewed toward permanent methods (e.g., toward sterilization, as in India) or toward long-acting reversible methods (e.g., toward IUDs in Egypt). In countries that do not have leanings toward longacting or permanent methods, elimination of unwanted fertility among those with met need is likely to produce lower overall unwanted fertility. Even in countries with a leaning toward long-acting reversible methods and with relatively high unwanted fertility, a focus on reducing unwanted fertility among those with met need would be desirable.

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ACKNOWLEDGMENTS The FALAH project was implemented by the Population Council with support from the United States Agency for International Development through a cooperative agreement.

June 2014


Reducing unmet need by supporting women with met need.

Time discounting and smoking behavior: evidence from a panel survey(*).

Unmet need, intention to use contraceptives and unwanted pregnancy in rural bangladesh.

Unwanted childbearing and household food insecurity in the United States.

Regional differences in unmet need for contraception in Kenya: insights from survey data.

Fertility desires, unmet need for family planning, and unwanted pregnancies among HIV-infected women in care in Kinshasa, DR Congo.

Sayana® Press: can it be a "game changer" for reducing unmet need for family planning?

Equity in the utilization of physician and inpatient hospital services: evidence from Korean health panel survey.

Unmet clinical need in autoimmune liver diseases.

'Toxgnostics': an unmet need in cancer medicine.

Assessing the need for a new nationally representative household panel survey in the United States.

Global Neurosurgery: The Unmet Need.

Understanding unmet need: history, theory, and measurement.

Socioeconomic position and early adolescent smoking development: evidence from the British Youth Panel Survey (1994-2008).

Unmet need for contraception: issues and challenges.

Pharmacometrics in pregnancy: An unmet need.

The challenges of reducing greenhouse gas emissions and air pollution through energy sources: evidence from a panel of developed countries.

Assessing unmet medical need in India: A regulatory riddle?

HyperLp(a)lipoproteinaemia: unmet need of diagnosis and treatment?

Capturing Unmet Therapy Need Among Young Children With Developmental Delay Using National Survey Data.

Pathways between perceived discrimination and health among immigrants: evidence from a large national panel survey in Germany.

Life after ibrutinib? A new unmet need in CLL.

Evidence of clinical utility: an unmet need in molecular diagnostics for patients with cancer.

Coverage, timeliness, and determinants of immunization completion in Pakistan: evidence from the Demographic and Health Survey (2006-07).