11
Unmet Need for Family Planning: Past Achievements and Remaining Challenges Kazuyo Machiyama, PhD1
1 Department of Population Health, London School of Hygiene and
Tropical Medicine, London, United Kingdom Semin Reprod Med 2015;33:11–16
Abstract
Keywords
► unmet need for family planning ► unintended pregnancy ► fertility
Address for correspondence John Cleland, MA, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom (e-mail: [email protected]).
Globally, the percentage of married fecund women with unmet need—who use no contraceptive method despite wishing to avoid childbearing for two years or more—fell from 22% in 1970 to 12% in 2010. Substantial health, economic and environmental, and demographic benefits have resulted from this change. Promotion of contraception is one of the great success stories of the past 50 years. However, unmet need remains high in sub-Saharan Africa, at 25%, because of insufficient knowledge of methods, social opposition, and fear of health effects. In addition to obvious factors such as political commitment and adequate funding, success in this region will require improvement in continuation of use and the range of available methods.
In the face of skepticism, supporters of the international family planning movement were obliged to demonstrate the existence of a need, or potential demand, for averting pregnancy in the poor, high-fertility countries of Africa, Asia, and Latin America. The term “unmet need for family planning” was coined in 1978 to describe women who wanted no more children but were using no method to achieve this wish, and since then, it has played an important role in research, evaluation, and advocacy.1 The concept has proved to be an invaluable bridge between approaches to fertility control based on principles of women’s reproductive rights and a demographic-economic rationale. Fulfillment of unmet need is clearly consistent with human rights and would also achieve the fertility-reduction goals of governments.2 At the 1994 International Conference on Population and Development, reducing unmet need became the central justification for investment in family planning and its legitimacy was further strengthened by its addition in 2007 as a target in the Millennium Development Goals (MDGs) and again in 2012 when it became a centerpiece at the London Summit on Family Planning. This paper addresses the following questions. How is unmet need measured and how valid is the concept? What is its magnitude? What are the reasons for it? What can be gained from reducing it? And how can it be reduced?
Issue Theme Global Women’s Health: Challenges and Opportunities; Guest Editor, Eli Y. Adashi, MD, MS, MA (ad eundem), CPE, FACOG
Concept and Measurement Though the basic concept of unmet need—nonuse of contraception among women stating a desire to avoid pregnancy—is straightforward, its precise measurement from the Demographic and Health Survey (DHS) program and similar surveys is complex and has undergone multiple variations since its origin in 1978, before a recent formulation achieved a broad consensus.3 Early on, unmet need was expanded to include women who want more children but wish to postpone the next birth for two years or more. The choice of the two-year cut-off is arbitrary but sensible. More complex issues concerned the handling of women who are not currently exposed to the risk of conception because they are already pregnant, in a state of lactational amenorrhea, sexually inactive, or infecund. All such women have a sound reason for nonuse of contraception regardless of future reproductive aspirations. Infecundity is judged to be a permanent state; thus, infecund women are excluded. Conversely, pregnancy and lactational amenorrhea are transient states and, indeed, may have arisen as a result of prior unmet need. The solution is to classify women according to their answers to a retrospective question on whether they wanted to become pregnant at the time of the most recent conception. The handling of sexual
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1395273. ISSN 1526-8004.
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Unmet Need for Family Planning
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inactivity differs according to marital status. The MDG indicator is restricted to married or cohabiting women and, for them, no allowance is made for sexual abstinence. Conversely, unmet need calculations for never or formerly married women are based on those who report sex in the past one (or three) months. In addition, many estimates treat users of “traditional” methods, mainly coitus interruptus and periodic abstinence, which have high failure rates, as nonusers.4 The implicit assumption is that they lack access to, or information about, more effective alternatives. The major criticism of the concept of unmet need stems from the fact that it is imposed by analysts on the basis of the discrepancy between preferences and behavior rather than from a direct expression of need by women themselves.5 Though it is commonly asserted that women with unmet need simply lack information on, or access to, methods, large proportions of these women report in surveys that they do not intend to adopt contraception in the future.6 Clearly, unmet need cannot be equated with a pressing current demand for contraception and, no doubt, some unmet need is spurious, stemming from weak or ambivalent desires to avoid future pregnancy or from a low perceived risk of conception. However, unmet need cannot be dismissed as an illusory rhetorical concept for three main reasons. First, the global incidence of unintended pregnancies taken to term or aborted, stemming largely from unmet need, is indisputably high. In 2008, it was estimated that 41% of all pregnancies were unintended, with a ratio of abortions to live births of 1.25.7 Second, the reduction of unmet need, rather than changes in desired number of children, has been the main driver of increased contraceptive use and decline in fertility.8,9 Third, qualitative research reveals the existence of genuine barriers to adoption of contraception among women wishing to avoid pregnancy.10,11
In sum, unmet need is a valid, if imprecise, indicator of latent or potential demand for contraception in the medium to long term. Differences in unmet need between national or subnational populations thus can be used to indicate where family planning investments will bring most benefit.
Trends National and regional estimates of contraceptive use and unmet need have been compiled from survey data, complemented by modeling.12 ►Fig. 1 shows the trends between 1970 and 2010 in the percentage of married or cohabiting fecund women currently using any method of contraception (contraceptive prevalence) and the percentage wanting no more children for at least two years but using no method (unmet need). In Europe and Northern America, prevalence was already high and unmet need low in 1970 and changes since then have been modest. By contrast, trends in Asia and Latin America were spectacular. In 1970, the levels of contraceptive use and unmet need were similar to each other. In the following 40 years, contraceptive prevalence doubled and unmet need fell from over 25 to 10%. The main exceptions, with unmet need at 25% or higher, are Pakistan and Nepal in Asia and Guatemala and Guyana in Latin America. Similar changes took place in Northern Africa, but unmet need was higher in 2010 than in the other two developing regions at 15%. In sub-Saharan Africa, though prevalence increased from 5 to 24%, it remains much lower than elsewhere and unmet need was static at approximately 25%. In this region, the majority of unmet need stems from women who wish to postpone the next birth, whereas in Asia and Latin America, it stems primarily from those who want to cease childbearing altogether.6
Fig. 1 Trends in contraceptive prevalence and unmet need for family planning, by region, 1970–2010.
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Unmet Need for Family Planning
Fig. 2 Percent distribution of contraceptive users by method in 10 countries.
13
Causes of Unmet Need Policy discussions of the reasons for unmet need tend to be dominated by two themes: lack of access and opposition by husbands. Access is a very elastic term, encompassing information about methods and services, geographic proximity to services, affordability, and acceptability. Though “universal access to reproductive health” is an MDG target, no comprehensive measure of access has been developed and thus nonuse is often erroneously equated with lack of access. Lack of knowledge is rarely cited by women as a reason for nonuse, except in West and Central Africa, where contraceptive use is low and little effort has been made to popularize family planning.15,16 Once knowledge is in place, distance or traveling time to a supply source appears to be a surprisingly minor determinant of uptake and is rarely mentioned by women.17 Similarly, cost is not a barrier in most countries, because services are provided free of charge or at subsidized prices. Acceptability is the most difficult dimension of access to assess. In common with other radical innovations that strike at the central concerns of sex, procreation, and food, the advent of contraception may be greeted with anxiety, fear, and even hostility. In the late 19th and early 20th centuries, birth control was condemned in Europe and the United States by politicians, the medical profession, and churches. In more recent decades, outright opposition by elite groups has been uncommon and the Vatican edict against modern methods is widely ignored. Nevertheless, the fear and anxiety evoked by contraception has been clearly documented in several settings.10,11,18,19 Contrary to common belief, men typically want similar numbers of children as women, and report similar attitudes to contraception and similar levels of use.20 Their level of unmet need is only slightly lower than that of women.21,22 When spouses disagree about future childbearing, it is by no means inevitable that husbands’ wishes prevail.23 It remains true, however, that wives are often uncertain about husbands’ attitudes to contraception or perceive opposition where none exists. Between 5 and 15% of women report in African DHSs that they conceal their use of contraception from husbands and these figures should be regarded as lower-bound estimates. Misperceptions matter. The single most common reason cited by women in surveys for nonuse is fear of side effects, together with health concerns. The extent to which it reflects underlying anxiety or ambivalence about contraception in general is uncertain. This reason for nonuse is given as often in countries where use is high (and by implication widely accepted both socially and morally) as where it is low, and as often among past users as never users.15 It is also the dominant reason for discontinuation of use.24 Side effects reported by users of hormonal methods include those for which little biological foundation exists, such as nausea and headaches, and others that are clinically verifiable, such as menstrual disturbance. The second most common reason for nonuse in women with unmet need is infrequent sex, more frequently Seminars in Reproductive Medicine
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While global unmet need in married women is estimated to have fallen from 22 to 12% since 1970, the absolute numbers increased from 127 to 142 million, because of the growth of population. Asia, because of its huge population, made the largest contribution of 83.6 million in 2010, followed by sub-Saharan Africa with 32 million.12 The MDG indicator of unmet need is confined to married women, but, of course, sexually active unmarried women also have a need for contraception. Though survey data are patchy for Asia and Northern Africa, estimates from specialized enquiries have been made. In developing regions as a whole, contraceptive prevalence among unmarried women who report sex in the past three months is similar to that among married women but unmet need is higher, 22 versus 12%, because the unmarried are much less likely to want a child in the next two years. Nearly one-fifth of total unmet need is contributed by sexually active unmarried women.13 The inclusion of single women and the classification of users of traditional methods as nonusers inflate the number of women with unmet need. With this definition, it was estimated that 222 million women in developing countries had an unmet need in 2012, equivalent to 26% of all married and sexually active unmarried women. In the 69 poorest countries, unmet need was higher at 39%.4 These high figures are the ones favored in advocacy and policy documents. An implicit underlying assumption of most discussions of unmet need is that use of an effective method fully satisfies couples’ freedom of choice with regard to ways of avoiding pregnancy. However, the range of methods used in many countries is very narrow and choice of method is, in reality, limited, as illustrated in ►Fig. 2.14 In sub-Saharan Africa, either oral contraceptives (e.g., Zimbabwe), or injectables (e.g., Ethiopia), or both together dominate. In India, female sterilization accounts for most protection, while in neighboring Bangladesh, it is the pill. Similar stark contrasts can be seen in Europe and the Arab States. These highly skewed distributions often reflect past policy decisions to promote particular methods. Once a method becomes established, it becomes favored both by providers and by clients, because both groups prefer the familiar to the unfamiliar. The disadvantages of reliance on one or two methods will be discussed further.
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mentioned in high- than in low-prevalence countries. In answer to an independent question, 44 to 55% of women in 46 DHSs giving this reason reported coitus in the preceding three months compared with 79 to 86% of those giving another reason for nonuse, thus providing some, albeit weak, support for the validity of infrequent sex as a reason.15 In conclusion, the balance of evidence suggests that unfamiliarity with modern methods and ignorance of sources of supply, together with initial social resistance, are major barriers during the early years of family planning programs. These barriers fade over time, but health concerns and fear of side effects assume greater prominence. As contraception spreads, unmet need is increasingly associated with low perceived risk of conception, because of infrequent sex or other reasons.
Benefits of Reducing Unmet Need Because of its direct link to family sizes and population change, reduced unmet need and increased contraceptive use has a uniquely wide range of demographic, economic, and environmental benefits, in addition to its well-documented health advantages for women and children.
Demography Since 1820, the population of the planet has grown from one to seven billion and a further increase to over nine billion by mid-century is almost inevitable. But the end of the era of growth is in sight, thanks largely to the rapid spread of contraception. The apocalyptic and Malthusian visions of an endless cycle of poverty and famine, fuelled by rapid growth in population, that gained prominence in the 1960s, have been averted. Fertility in Asia and Latin America is now close to two births per woman, the level required to maintain long-term stability of population size, though growth will continue for several decades because of the large fraction in the reproductive ages (►Fig. 3).25 The biggest uncertainty about future population growth concerns sub-Saharan Africa. Fertility is now projected to fall from 5.0 births in 2010–2015 to 3.2 births by mid-century and, in this scenario, the population of sub-Saharan Africa will grow between 2010 and 2050 from 0.8 to 2.1 billion.25 This slow pace of fertility
decline could be accelerated by concerted efforts to address unmet need.
Economics Reduction of unmet need and the consequent fall in unintended births have both short- and longer-term economic benefits. In 15 African countries, it was estimated that, on average, the financial benefits would exceed the costs of a steady elimination of unmet need for family planning by an impressive margin. For every $1000 spent on contraception, savings of $3,700 over a ten-year period would accrue, with the largest contribution from reduced costs of meeting MDG targets on primary school enrolment, followed by drops in costs of obstetric care and immunization.26 The longer-term benefits of increased contraception and declines in fertility are potentially more significant than these short-term gains. In high-fertility countries, approximately 40% of the total population is aged less than 15 years, consuming more than they produce. Fertility decline brings in its wake an era when the ratio of adult workers to dependent young rises. New opportunities arise for increased savings and investment in industry and agriculture, for improvements in the quality of education and training, and for increased employment of women. If these opportunities are seized and sound macro-economic policies are in place, rapid economic advance can be made, as occurred in much of Asia.27
Environment Evidence is accumulating that humanity is approaching planetary boundaries, which, if exceeded, have potentially catastrophic consequences.28 Of course, affluence rather than human numbers is primarily responsible for most global threats, such as ocean acidification and carbon dioxide emissions. However, reduction of unmet need and population growth could make a major contribution to control of emissions in the medium to long term, because today’s poor countries, where population growth is concentrated, will become wealthier.29 Global population increase is more immediately implicated in further loss of biodiversity and further land use change and associated pressure on freshwater due to increased demand for food. Local environmental problems are likely to be most severe in sub-Saharan Africa, the only region where increased rural as well as urban population is expected. Thus, in many parts of Africa, fragile ecosystems must support a growing density of population, with the danger of overcropping and overgrazing. In the countries of the Sahel, the regular food crises can only be made worse by populations that are expected to triple in size by mid-century. Reduction of unmet need for family planning will help to reduce the severity of these problems.
Health
Fig. 3 Trends in total fertility rate, by region, 1950–2050.
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Reduction in the number of unintended pregnancies is the greatest health benefit of contraception. One-third of maternal deaths could be avoided by fulfillment of unmet need. By preventing high-risk pregnancies, especially in women of high parities, and those that would have ended in unsafe
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abortion, increased contraceptive use will also reduce the maternal mortality ratio.30 Reduction of mistimed births also improves perinatal outcomes and child survival by lengthening interpregnancy intervals. In developing countries, the risk of prematurity and low birth weight doubles when conception occurs within six months of a previous birth.31 The public health implications of these findings are underscored by two considerations: prematurity is now the second most common cause of underfive mortality in developing countries; and fetal growth is an important risk factor for coronary heart disease and stroke in adult life. Survival in infancy and early childhood is also adversely affected by inadequate spacing of births.30,32 In high-fertility countries, elimination of all birth intervals of under two years would reduce infant mortality by 10% and early childhood mortality by 21%.33
Priorities for Action The extensive literature on effective promotion of family planning in poor countries emphasizes the need for political commitment, adequate funding, sound logistics systems, well-trained and supervised staff offering services of reasonable quality, specific outreach strategies to improve access for underserved populations, task shifting to allow mid-level staff to provide clinical methods, and so on.34–36 Rather than repeat these truisms, this section focuses on priorities in sub-Saharan Africa that are not so widely appreciated. The first priority, of particular importance in Western and Central Africa, is to increase knowledge and the social acceptability of modern contraception by use of mass media promotion, supplemented by campaigns targeting local religious and traditional leaders. The family planning movement has accumulated more experience with the use of mass media than any other branch of public health, and the evidence of effectiveness is impressive.34 Increasing access to services without investment in demand-creation will be ineffective. A second priority is to reduce early discontinuation of methods and encourage prompt switching to alternatives, when necessary. ►Fig. 4, derived from a recent WHO
Cleland, Machiyama
Fig. 5 Percent of women who switched to a modern and to a traditional method within 3 months of method-related discontinuation, for 17 countries.
publication, summarizes discontinuation probabilities for 19 developing countries in the form of box and whisker plots for the six most commonly used reversible methods.24 For all methods, except the IUD, approximately 40% or more couples discontinued use within 12 months of starting. The main reason for stopping varies by method: side effects and health concerns for pills, injectables, and IUDs; inconvenience for condoms; and failure for withdrawal and abstinence. Discontinuation is not a problem if couples are able and willing to switch to an alternative, but many do not switch and are therefore at risk of an unintended pregnancy. ►Fig. 5 shows that switching, after discontinuation for reasons that imply dissatisfaction with the method, is particularly low in African countries. The evidence in ►Figs. 2, 4, and 5 identifies a severe challenge for contraceptive promotion in Africa. Hormonal methods dominate, but discontinuation is common and switching is low. In Kenya, half of unmet need comprises women who have previously used pills and/or injectables, and in Ghana, the equivalent figure is one-third.37 One clear priority is to encourage persistence of use by better counselling and follow-up, perhaps by greater use of mobile phone technology. The other priority is to widen choice of method by promoting, for instance, voluntary sterilization and IUDs. Neither priority is simple to achieve. Evidence that enhanced counselling reduces discontinuation is weak, though new tools are being developed.38 Widening method-choice demands simultaneous attention to logistics, staff training, and demand creation. Few countries have succeeded in making radical changes in the past two decades.39 Despite the challenges, improved adherence among contraceptive adopters is as important in reducing unmet need as attracting new users.
Concluding Comments
Fig. 4 Probabilities of discontinuation at 12 months per 100 episodes, by method, 19 countries.
The promotion of contraception in the low- and middleincome countries of Asia and Latin America has been one the great success stories of the past 50 years. Perhaps the most important lesson is that family planning can flourish even in very poor and ill-educated populations, thus disproving the Seminars in Reproductive Medicine
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Unmet Need for Family Planning
Unmet Need for Family Planning
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common but pernicious view that the poor necessarily need or want large families. The remaining challenge lies largely in sub-Saharan Africa, where fertility and unmet need remain high. There are grounds for optimism. After nearly two decades of relative neglect, interest in family planning has been revitalized, as evidenced by the 2012 London Summit and three recent well-attended international conferences, held in Uganda, Senegal, and Ethiopia. Attitudes of political elites in Africa are becoming more favorable and international funding more generous, than in the past. Rapid recent progress has been documented in Ethiopia, Malawi, and Rwanda. Reduction of unmet need for family planning will bring economic, environmental, and health benefits in a region that badly needs them.
17 Jones EF. The Availability of Contraceptive Services: World Fertility
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Unmet Need for Family Planning: Past Achievements and Remaining Challenges Kazuyo Machiyama, PhD1
1 Department of Population Health, London School of Hygiene and
Tropical Medicine, London, United Kingdom Semin Reprod Med 2015;33:11–16
Abstract
Keywords
► unmet need for family planning ► unintended pregnancy ► fertility
Address for correspondence John Cleland, MA, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom (e-mail: [email protected]).
Globally, the percentage of married fecund women with unmet need—who use no contraceptive method despite wishing to avoid childbearing for two years or more—fell from 22% in 1970 to 12% in 2010. Substantial health, economic and environmental, and demographic benefits have resulted from this change. Promotion of contraception is one of the great success stories of the past 50 years. However, unmet need remains high in sub-Saharan Africa, at 25%, because of insufficient knowledge of methods, social opposition, and fear of health effects. In addition to obvious factors such as political commitment and adequate funding, success in this region will require improvement in continuation of use and the range of available methods.
In the face of skepticism, supporters of the international family planning movement were obliged to demonstrate the existence of a need, or potential demand, for averting pregnancy in the poor, high-fertility countries of Africa, Asia, and Latin America. The term “unmet need for family planning” was coined in 1978 to describe women who wanted no more children but were using no method to achieve this wish, and since then, it has played an important role in research, evaluation, and advocacy.1 The concept has proved to be an invaluable bridge between approaches to fertility control based on principles of women’s reproductive rights and a demographic-economic rationale. Fulfillment of unmet need is clearly consistent with human rights and would also achieve the fertility-reduction goals of governments.2 At the 1994 International Conference on Population and Development, reducing unmet need became the central justification for investment in family planning and its legitimacy was further strengthened by its addition in 2007 as a target in the Millennium Development Goals (MDGs) and again in 2012 when it became a centerpiece at the London Summit on Family Planning. This paper addresses the following questions. How is unmet need measured and how valid is the concept? What is its magnitude? What are the reasons for it? What can be gained from reducing it? And how can it be reduced?
Issue Theme Global Women’s Health: Challenges and Opportunities; Guest Editor, Eli Y. Adashi, MD, MS, MA (ad eundem), CPE, FACOG
Concept and Measurement Though the basic concept of unmet need—nonuse of contraception among women stating a desire to avoid pregnancy—is straightforward, its precise measurement from the Demographic and Health Survey (DHS) program and similar surveys is complex and has undergone multiple variations since its origin in 1978, before a recent formulation achieved a broad consensus.3 Early on, unmet need was expanded to include women who want more children but wish to postpone the next birth for two years or more. The choice of the two-year cut-off is arbitrary but sensible. More complex issues concerned the handling of women who are not currently exposed to the risk of conception because they are already pregnant, in a state of lactational amenorrhea, sexually inactive, or infecund. All such women have a sound reason for nonuse of contraception regardless of future reproductive aspirations. Infecundity is judged to be a permanent state; thus, infecund women are excluded. Conversely, pregnancy and lactational amenorrhea are transient states and, indeed, may have arisen as a result of prior unmet need. The solution is to classify women according to their answers to a retrospective question on whether they wanted to become pregnant at the time of the most recent conception. The handling of sexual
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1395273. ISSN 1526-8004.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
John Cleland, MA1
Unmet Need for Family Planning
Cleland, Machiyama
inactivity differs according to marital status. The MDG indicator is restricted to married or cohabiting women and, for them, no allowance is made for sexual abstinence. Conversely, unmet need calculations for never or formerly married women are based on those who report sex in the past one (or three) months. In addition, many estimates treat users of “traditional” methods, mainly coitus interruptus and periodic abstinence, which have high failure rates, as nonusers.4 The implicit assumption is that they lack access to, or information about, more effective alternatives. The major criticism of the concept of unmet need stems from the fact that it is imposed by analysts on the basis of the discrepancy between preferences and behavior rather than from a direct expression of need by women themselves.5 Though it is commonly asserted that women with unmet need simply lack information on, or access to, methods, large proportions of these women report in surveys that they do not intend to adopt contraception in the future.6 Clearly, unmet need cannot be equated with a pressing current demand for contraception and, no doubt, some unmet need is spurious, stemming from weak or ambivalent desires to avoid future pregnancy or from a low perceived risk of conception. However, unmet need cannot be dismissed as an illusory rhetorical concept for three main reasons. First, the global incidence of unintended pregnancies taken to term or aborted, stemming largely from unmet need, is indisputably high. In 2008, it was estimated that 41% of all pregnancies were unintended, with a ratio of abortions to live births of 1.25.7 Second, the reduction of unmet need, rather than changes in desired number of children, has been the main driver of increased contraceptive use and decline in fertility.8,9 Third, qualitative research reveals the existence of genuine barriers to adoption of contraception among women wishing to avoid pregnancy.10,11
In sum, unmet need is a valid, if imprecise, indicator of latent or potential demand for contraception in the medium to long term. Differences in unmet need between national or subnational populations thus can be used to indicate where family planning investments will bring most benefit.
Trends National and regional estimates of contraceptive use and unmet need have been compiled from survey data, complemented by modeling.12 ►Fig. 1 shows the trends between 1970 and 2010 in the percentage of married or cohabiting fecund women currently using any method of contraception (contraceptive prevalence) and the percentage wanting no more children for at least two years but using no method (unmet need). In Europe and Northern America, prevalence was already high and unmet need low in 1970 and changes since then have been modest. By contrast, trends in Asia and Latin America were spectacular. In 1970, the levels of contraceptive use and unmet need were similar to each other. In the following 40 years, contraceptive prevalence doubled and unmet need fell from over 25 to 10%. The main exceptions, with unmet need at 25% or higher, are Pakistan and Nepal in Asia and Guatemala and Guyana in Latin America. Similar changes took place in Northern Africa, but unmet need was higher in 2010 than in the other two developing regions at 15%. In sub-Saharan Africa, though prevalence increased from 5 to 24%, it remains much lower than elsewhere and unmet need was static at approximately 25%. In this region, the majority of unmet need stems from women who wish to postpone the next birth, whereas in Asia and Latin America, it stems primarily from those who want to cease childbearing altogether.6
Fig. 1 Trends in contraceptive prevalence and unmet need for family planning, by region, 1970–2010.
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Unmet Need for Family Planning
Fig. 2 Percent distribution of contraceptive users by method in 10 countries.
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Causes of Unmet Need Policy discussions of the reasons for unmet need tend to be dominated by two themes: lack of access and opposition by husbands. Access is a very elastic term, encompassing information about methods and services, geographic proximity to services, affordability, and acceptability. Though “universal access to reproductive health” is an MDG target, no comprehensive measure of access has been developed and thus nonuse is often erroneously equated with lack of access. Lack of knowledge is rarely cited by women as a reason for nonuse, except in West and Central Africa, where contraceptive use is low and little effort has been made to popularize family planning.15,16 Once knowledge is in place, distance or traveling time to a supply source appears to be a surprisingly minor determinant of uptake and is rarely mentioned by women.17 Similarly, cost is not a barrier in most countries, because services are provided free of charge or at subsidized prices. Acceptability is the most difficult dimension of access to assess. In common with other radical innovations that strike at the central concerns of sex, procreation, and food, the advent of contraception may be greeted with anxiety, fear, and even hostility. In the late 19th and early 20th centuries, birth control was condemned in Europe and the United States by politicians, the medical profession, and churches. In more recent decades, outright opposition by elite groups has been uncommon and the Vatican edict against modern methods is widely ignored. Nevertheless, the fear and anxiety evoked by contraception has been clearly documented in several settings.10,11,18,19 Contrary to common belief, men typically want similar numbers of children as women, and report similar attitudes to contraception and similar levels of use.20 Their level of unmet need is only slightly lower than that of women.21,22 When spouses disagree about future childbearing, it is by no means inevitable that husbands’ wishes prevail.23 It remains true, however, that wives are often uncertain about husbands’ attitudes to contraception or perceive opposition where none exists. Between 5 and 15% of women report in African DHSs that they conceal their use of contraception from husbands and these figures should be regarded as lower-bound estimates. Misperceptions matter. The single most common reason cited by women in surveys for nonuse is fear of side effects, together with health concerns. The extent to which it reflects underlying anxiety or ambivalence about contraception in general is uncertain. This reason for nonuse is given as often in countries where use is high (and by implication widely accepted both socially and morally) as where it is low, and as often among past users as never users.15 It is also the dominant reason for discontinuation of use.24 Side effects reported by users of hormonal methods include those for which little biological foundation exists, such as nausea and headaches, and others that are clinically verifiable, such as menstrual disturbance. The second most common reason for nonuse in women with unmet need is infrequent sex, more frequently Seminars in Reproductive Medicine
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While global unmet need in married women is estimated to have fallen from 22 to 12% since 1970, the absolute numbers increased from 127 to 142 million, because of the growth of population. Asia, because of its huge population, made the largest contribution of 83.6 million in 2010, followed by sub-Saharan Africa with 32 million.12 The MDG indicator of unmet need is confined to married women, but, of course, sexually active unmarried women also have a need for contraception. Though survey data are patchy for Asia and Northern Africa, estimates from specialized enquiries have been made. In developing regions as a whole, contraceptive prevalence among unmarried women who report sex in the past three months is similar to that among married women but unmet need is higher, 22 versus 12%, because the unmarried are much less likely to want a child in the next two years. Nearly one-fifth of total unmet need is contributed by sexually active unmarried women.13 The inclusion of single women and the classification of users of traditional methods as nonusers inflate the number of women with unmet need. With this definition, it was estimated that 222 million women in developing countries had an unmet need in 2012, equivalent to 26% of all married and sexually active unmarried women. In the 69 poorest countries, unmet need was higher at 39%.4 These high figures are the ones favored in advocacy and policy documents. An implicit underlying assumption of most discussions of unmet need is that use of an effective method fully satisfies couples’ freedom of choice with regard to ways of avoiding pregnancy. However, the range of methods used in many countries is very narrow and choice of method is, in reality, limited, as illustrated in ►Fig. 2.14 In sub-Saharan Africa, either oral contraceptives (e.g., Zimbabwe), or injectables (e.g., Ethiopia), or both together dominate. In India, female sterilization accounts for most protection, while in neighboring Bangladesh, it is the pill. Similar stark contrasts can be seen in Europe and the Arab States. These highly skewed distributions often reflect past policy decisions to promote particular methods. Once a method becomes established, it becomes favored both by providers and by clients, because both groups prefer the familiar to the unfamiliar. The disadvantages of reliance on one or two methods will be discussed further.
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mentioned in high- than in low-prevalence countries. In answer to an independent question, 44 to 55% of women in 46 DHSs giving this reason reported coitus in the preceding three months compared with 79 to 86% of those giving another reason for nonuse, thus providing some, albeit weak, support for the validity of infrequent sex as a reason.15 In conclusion, the balance of evidence suggests that unfamiliarity with modern methods and ignorance of sources of supply, together with initial social resistance, are major barriers during the early years of family planning programs. These barriers fade over time, but health concerns and fear of side effects assume greater prominence. As contraception spreads, unmet need is increasingly associated with low perceived risk of conception, because of infrequent sex or other reasons.
Benefits of Reducing Unmet Need Because of its direct link to family sizes and population change, reduced unmet need and increased contraceptive use has a uniquely wide range of demographic, economic, and environmental benefits, in addition to its well-documented health advantages for women and children.
Demography Since 1820, the population of the planet has grown from one to seven billion and a further increase to over nine billion by mid-century is almost inevitable. But the end of the era of growth is in sight, thanks largely to the rapid spread of contraception. The apocalyptic and Malthusian visions of an endless cycle of poverty and famine, fuelled by rapid growth in population, that gained prominence in the 1960s, have been averted. Fertility in Asia and Latin America is now close to two births per woman, the level required to maintain long-term stability of population size, though growth will continue for several decades because of the large fraction in the reproductive ages (►Fig. 3).25 The biggest uncertainty about future population growth concerns sub-Saharan Africa. Fertility is now projected to fall from 5.0 births in 2010–2015 to 3.2 births by mid-century and, in this scenario, the population of sub-Saharan Africa will grow between 2010 and 2050 from 0.8 to 2.1 billion.25 This slow pace of fertility
decline could be accelerated by concerted efforts to address unmet need.
Economics Reduction of unmet need and the consequent fall in unintended births have both short- and longer-term economic benefits. In 15 African countries, it was estimated that, on average, the financial benefits would exceed the costs of a steady elimination of unmet need for family planning by an impressive margin. For every $1000 spent on contraception, savings of $3,700 over a ten-year period would accrue, with the largest contribution from reduced costs of meeting MDG targets on primary school enrolment, followed by drops in costs of obstetric care and immunization.26 The longer-term benefits of increased contraception and declines in fertility are potentially more significant than these short-term gains. In high-fertility countries, approximately 40% of the total population is aged less than 15 years, consuming more than they produce. Fertility decline brings in its wake an era when the ratio of adult workers to dependent young rises. New opportunities arise for increased savings and investment in industry and agriculture, for improvements in the quality of education and training, and for increased employment of women. If these opportunities are seized and sound macro-economic policies are in place, rapid economic advance can be made, as occurred in much of Asia.27
Environment Evidence is accumulating that humanity is approaching planetary boundaries, which, if exceeded, have potentially catastrophic consequences.28 Of course, affluence rather than human numbers is primarily responsible for most global threats, such as ocean acidification and carbon dioxide emissions. However, reduction of unmet need and population growth could make a major contribution to control of emissions in the medium to long term, because today’s poor countries, where population growth is concentrated, will become wealthier.29 Global population increase is more immediately implicated in further loss of biodiversity and further land use change and associated pressure on freshwater due to increased demand for food. Local environmental problems are likely to be most severe in sub-Saharan Africa, the only region where increased rural as well as urban population is expected. Thus, in many parts of Africa, fragile ecosystems must support a growing density of population, with the danger of overcropping and overgrazing. In the countries of the Sahel, the regular food crises can only be made worse by populations that are expected to triple in size by mid-century. Reduction of unmet need for family planning will help to reduce the severity of these problems.
Health
Fig. 3 Trends in total fertility rate, by region, 1950–2050.
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Reduction in the number of unintended pregnancies is the greatest health benefit of contraception. One-third of maternal deaths could be avoided by fulfillment of unmet need. By preventing high-risk pregnancies, especially in women of high parities, and those that would have ended in unsafe
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abortion, increased contraceptive use will also reduce the maternal mortality ratio.30 Reduction of mistimed births also improves perinatal outcomes and child survival by lengthening interpregnancy intervals. In developing countries, the risk of prematurity and low birth weight doubles when conception occurs within six months of a previous birth.31 The public health implications of these findings are underscored by two considerations: prematurity is now the second most common cause of underfive mortality in developing countries; and fetal growth is an important risk factor for coronary heart disease and stroke in adult life. Survival in infancy and early childhood is also adversely affected by inadequate spacing of births.30,32 In high-fertility countries, elimination of all birth intervals of under two years would reduce infant mortality by 10% and early childhood mortality by 21%.33
Priorities for Action The extensive literature on effective promotion of family planning in poor countries emphasizes the need for political commitment, adequate funding, sound logistics systems, well-trained and supervised staff offering services of reasonable quality, specific outreach strategies to improve access for underserved populations, task shifting to allow mid-level staff to provide clinical methods, and so on.34–36 Rather than repeat these truisms, this section focuses on priorities in sub-Saharan Africa that are not so widely appreciated. The first priority, of particular importance in Western and Central Africa, is to increase knowledge and the social acceptability of modern contraception by use of mass media promotion, supplemented by campaigns targeting local religious and traditional leaders. The family planning movement has accumulated more experience with the use of mass media than any other branch of public health, and the evidence of effectiveness is impressive.34 Increasing access to services without investment in demand-creation will be ineffective. A second priority is to reduce early discontinuation of methods and encourage prompt switching to alternatives, when necessary. ►Fig. 4, derived from a recent WHO
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Fig. 5 Percent of women who switched to a modern and to a traditional method within 3 months of method-related discontinuation, for 17 countries.
publication, summarizes discontinuation probabilities for 19 developing countries in the form of box and whisker plots for the six most commonly used reversible methods.24 For all methods, except the IUD, approximately 40% or more couples discontinued use within 12 months of starting. The main reason for stopping varies by method: side effects and health concerns for pills, injectables, and IUDs; inconvenience for condoms; and failure for withdrawal and abstinence. Discontinuation is not a problem if couples are able and willing to switch to an alternative, but many do not switch and are therefore at risk of an unintended pregnancy. ►Fig. 5 shows that switching, after discontinuation for reasons that imply dissatisfaction with the method, is particularly low in African countries. The evidence in ►Figs. 2, 4, and 5 identifies a severe challenge for contraceptive promotion in Africa. Hormonal methods dominate, but discontinuation is common and switching is low. In Kenya, half of unmet need comprises women who have previously used pills and/or injectables, and in Ghana, the equivalent figure is one-third.37 One clear priority is to encourage persistence of use by better counselling and follow-up, perhaps by greater use of mobile phone technology. The other priority is to widen choice of method by promoting, for instance, voluntary sterilization and IUDs. Neither priority is simple to achieve. Evidence that enhanced counselling reduces discontinuation is weak, though new tools are being developed.38 Widening method-choice demands simultaneous attention to logistics, staff training, and demand creation. Few countries have succeeded in making radical changes in the past two decades.39 Despite the challenges, improved adherence among contraceptive adopters is as important in reducing unmet need as attracting new users.
Concluding Comments
Fig. 4 Probabilities of discontinuation at 12 months per 100 episodes, by method, 19 countries.
The promotion of contraception in the low- and middleincome countries of Asia and Latin America has been one the great success stories of the past 50 years. Perhaps the most important lesson is that family planning can flourish even in very poor and ill-educated populations, thus disproving the Seminars in Reproductive Medicine
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common but pernicious view that the poor necessarily need or want large families. The remaining challenge lies largely in sub-Saharan Africa, where fertility and unmet need remain high. There are grounds for optimism. After nearly two decades of relative neglect, interest in family planning has been revitalized, as evidenced by the 2012 London Summit and three recent well-attended international conferences, held in Uganda, Senegal, and Ethiopia. Attitudes of political elites in Africa are becoming more favorable and international funding more generous, than in the past. Rapid recent progress has been documented in Ethiopia, Malawi, and Rwanda. Reduction of unmet need for family planning will bring economic, environmental, and health benefits in a region that badly needs them.
17 Jones EF. The Availability of Contraceptive Services: World Fertility
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