Unmet Need Affects Millions

Contraceptive use has increased markedly in recent years in most developing countries, as has the desire for smaller families. Millions of couples, however, want to delay or avoid pregnancy but are not using contraception.

Many factors contribute to this unmet need for contraception, including lack of knowledge about contraception, fear of side effects, opposition from husbands, ambiguous feelings about contraception, dissatisfaction with methods, and poor access to, or a limited range of, contraceptive choices.

In the developing world, about one in four married women who wants to avoid a pregnancy is not using contraception, according to unpublished data from Demographic and Health Surveys.¹ That equals about 150 million women in the developing world.

In terms of total population with unmet needs, Asian countries have the largest numbers. India by far has the most, at 31 million couples. However, in terms of the percentage of married couples of reproductive age whose needs are unmet, sub-Saharan Africa leads the list. All of the six developing countries in which more than one-third of married women of reproductive age have unmet need are in sub-Saharan Africa (see table).²

Many others could also qualify as having unmet need for effective contraception, depending upon how surveys are designed and analyzed. These include sexually active unmarried women and men, users dissatisfied with their current method, those who use a method incorrectly, and those with a limited choice of methods.³ While most studies focus exclusively on unmet need for married women, some research is being done to measure the unmet contraceptive need for other groups.

Regardless of how "unmet need" is defined, tens of millions of couples want to avoid pregnancy but are not able to use contraception. Recent studies offer a clearer picture of barriers to contraception and how they operate, and may lead to practical ways to attract new contraceptive users.

Multiple reasons

Reasons for unmet need often overlap because of social and cultural factors that tend to influence sexual practices and reproductive health needs. Two extensive studies published in 1995 found that the major reasons for unmet contraceptive need were lack of knowledge, health concerns and ambivalence about future childbearing. Other important reasons, depending on the country, included opposition by family members and side effects.⁴ The studies only included responses from women.

"Many assume that if couples just had access to a method, they would use it, but this is a wrong assumption," says Dr. Nancy Yinger, who coordinated several recent studies on the causes of unmet need for contraception through the U.S.-based International Center for Research on Women (ICRW). "The causes and solutions are much more complicated than just lacking access. Even when contraception is available, many potential users lack knowledge and support, have a lot of fear, and face formidable social and cultural barriers to using contraception."

"Lack of knowledge" in survey responses can actually mean an absence of family planning services or information, says Dr. John Ross, who coordinates unmet need studies for The Futures Group International, a U.S.-based organization that studies reproductive health issues. This can be particularly important for certain population groups, he adds, especially postpartum women, adolescents and women living in rural areas of many countries.

"About 40 percent of unmet need falls in the first year postpartum," he says. "Working to join services across institutional gaps can help address this need." Linking family planning services with childhood immunization, oral rehydration treatments, and other early childhood services can make contraception available when a large amount of unmet need occurs, according to Dr. Ross.

Lack of knowledge is also closely connected to women's status within their family and communities. A study in Guatemala examined patterns of communication and decision-making that affected unmet contraceptive need. Women with unmet need were more likely to be in families where control over fertility or family planning was not discussed or encouraged and where women did not participate in decisions concerning reproductive and sexual matters. The study, coordinated by ICRW, used survey data from 275 people and in-depth interviews with 80 people, including men and unmarried women.⁵

"Although men and women have access to information on contraceptive methods from television, radio, brochures and other sources, many of them do not have an opportunity to discuss it with each other, face-to-face," explains Dr. Linda Asturias de Barrios, who directed the study through ESTUDIO 1360, a Guatemalan research center. "Moreover, the available health services that do allow for face-to-face interactions, such as health centers and community distributors, generally do not promote a psychological atmosphere that permits women and men to discuss such sensitive topics as sexuality, reproductive health and family planning." To address the findings of the study, the project is training local health workers as counselors, identifying 50 young women to participate in an education project and designing a sexual health educational curriculum, among other efforts.

Like the Guatemalan project, several recent studies have shown that barriers to individual use are part of larger social and cultural patterns. Using in-depth interviews and focus group discussions along with survey data, studies in Ghana, India, Pakistan, the Philippines and Zambia, as well as Guatemala, consistently found that lack of knowledge, fear of side effects and husband's support are the major factors accounting for unmet need.

Side effects

In many studies, the impact of contraceptives on a woman's health, whether real or perceived, is often a barrier. Concerns include side effects and unfounded fears about side effects or health consequences, based on lack of knowledge or false information. In the Pakistan study, a large portion of women who had heard of modern methods feared harmful effects from using them, ranging from 40 percent for female sterilization to 70 percent for the intrauterine device (IUD). "The body remains impure with an IUD insertion," said one woman, apparently referring to how IUDs can alter menstrual bleeding. "The IUD causes bleeding and spotting. One cannot remain pure. Therefore, I got the IUD removed." The study involved 1,310 married women and 554 of their husbands in urban and rural communities.⁶

One way to address obstacles related to side effects, health concerns and incorrect knowledge about contraceptives is better counseling. Counseling about side effects can improve continuation rates, thus lowering the portion of women who may fall into the unmet need category. For example, in a study among women in China using the injectable depot-medroxyprogesterone acetate (DMPA), about 200 women received detailed counseling about side effects and about 200 received only routine family planning counseling. One year after the women began using the method, discontinuation rates were almost four times higher among the group receiving routine counseling, 42 percent compared to 11 percent. The main reason for discontinuation was menstrual changes, the most common side effect of the method.⁷

Many providers do not counsel women about side effects. In 12 counties in sub-Saharan Africa, only about half of the women who chose a new method received information on that method's side effects, according to a study of the quality of family planning services. The portion informed about the method's side effects ranged from 24 percent in Burkina Faso to 68 percent in Botswana.⁸

Family role

Another consistent finding among recent studies is the importance of men and other family members. In two studies in sub-Saharan Africa, in Ghana and Zambia, unmet need was higher among couples who did not discuss birth control with each other.

In Ghana, only about a third of women with unmet need felt comfortable discussing contraception with their husbands, compared to about two-thirds of contraceptive users. Both groups of women saw husbands as important in making a decision about contraception. The study concluded that "men must be reached, at least initially, through culturally appropriate communication channels."⁹ For example, the Navrongo Community Health and Family Planning Project in Ghana does so through chiefs and heads of families.

In the Zambia study, done in or near a city, nearly nine of every 10 contraceptive users had at some point talked with their husbands about contraception. In contrast, only about two of every three women who had never used contraceptives but wished to avoid pregnancy had discussed contraception with their husbands.

When the research team presented results in community meetings, many participants urged that family planning information become available to men through neighborhood health committees. Men tend to gather at specific locations and times, creating opportunities to reach men with services.¹⁰

In the Philippines study, the researchers concluded that the difference in power between women and their husbands is a major factor accounting for unmet need. "Difficulties in initiating and refusing sexual relations characterize women with unmet need. In fact, unequal power between spouses in sexual matters often seems to complicate and exacerbate the other factors identified," concluded Dr. John Casterline of the Population Council and his colleagues. As one woman said, "Since he is my husband, his decision prevails." The study included surveys of nearly 2,000 women and men in Manila and a rural area.¹¹

In recent years, programs in Colombia, Ghana, India, Kenya, Mexico and other countries have begun efforts to involve men in reproductive health programs. In the Philippines, for example, Dr. Cesar Maglaya, a former FHI research fellow, has begun a male clinic at Dr. José Fabella Memorial Hospital in Manila, providing no-scalpel vasectomy to husbands of postpartum mothers. "With men, it is a matter of reaching out to them with accurate information and education about family planning and reproductive health, which includes sexually transmitted diseases, so they will realize that men play an important role in reproductive health," says Dr. Maglaya. "Men are beginning to volunteer in getting other men to have vasectomy now. Reproductive health programs must find ways to involve men."

The Pakistan study found that nearly nine of every 10 women perceived men's disapproval of contraceptive use as an obstacle to meeting their reproductive needs. Pilot programs have sought to involve men in Pakistan, but sustaining that effort has been challenging. A project in the city of Mardan, for example, used community educators working through a male-controlled community development council to contact men and couples about contraceptive use. In four years, the contraceptive prevalence in the area rose from 9 percent to 21 percent. But funding for the project ended.

Choices

Lacking a range of contraceptive choices can result in unmet need. Research in Vietnam found that expanding the mix of available methods should reduce unmet need substantially. The country has relied almost exclusively on the IUD, currently used by a third of all Vietnamese couples of reproductive age. "But it has stalled there for a number of years and is unlikely to go higher," explained Dr. Ross of The Futures Group International and colleagues in a recent paper. "Meanwhile, another one-sixth of couples have used it but stopped and they have only very limited choices. An unmet need focus, with a full choice of methods, would go far to correct this."¹²

In the 1970s and 1980s, adding a modern contraceptive method to a national program that was young and evolving often resulted in a significant increase in contraceptive prevalence. Adding a new method increased prevalence by about 12 percentage points, according to a 1989 study.¹³

-- William R. Finger

References

1. Center for Population, Health and Nutrition, U.S. Agency for International Development. Unmet need for family planning. Pop Briefs 1998.
2. Robey B, Ross J, Bhushan I. Meeting unmet need: new strategies. Popul Rep 1996; J(43):6-7.
3. Dixon-Mueller R, Germain A. Stalking the elusive "unmet need" for family planning. Stud Fam Plann 1992;23(5):330-35.
4. Westoff CF, Bankole A. Unmet Need: 1990-1994, Demographic and Health Surveys Comparative Studies No. 16. Calverton, MD: Macro International, 1995; Bongaarts J, Bruce J. The causes of unmet need for contraception and the social content of services. Stud Fam Plann 1995;26(2):57-75.
5. Asturias de Barrios L, Mejía de Rodas I, Nieves I, et al. Unmet Need for Family Planning in a Peri-urban Community of Guatemala City. Washington: International Center for Research on Women, 1997.
6. The Gap between Reproductive Intentions and Behaviour: A Study of Punjabi Men and Women. Islamabad: Population Council, 1998.
7. Lei ZW, Wu SC, Garceau RJ, et al. Effect of pretreatment counseling on discontinuation rates in Chinese women given depo-medroxyprogesterone acetate for contraception. Contraception 1996;53(6):357-61.
8. Miller K, Miller R, Askew I, et al. Clinic-based Family Planning and Reproductive Health Services in Africa: Findings from Situation Analysis Studies. (New York: Population Council, 1998)80.
9. Unmet Need for Contraception: Unmet Need in a Traditional West African Setting. New York: Population Council, 1998.
10. Biddlecom AE, Kaona FAD. The nature of unmet need for contraception in an urban African setting. Presentation at the Seminar on Reproductive Change in Sub-Saharan Africa, sponsored by the International Union for the Scientific Study of Population, in collaboration with the African Population Policy Research Centre, Nairobi, Kenya, November 2-4, 1998.
11. Casterline JB, Pérez AE, Biddlecom AE. Factors underlying the unmet need for family planning in the Philippines. Stud Fam Plann 1997;28(3):173-91.
12. Ross JA, Barkat A, Pham SB, et al. Unmet need: prototype action programs for Bangladesh, India and Vietnam. Presentation at the Population Association of America meeting, New Orleans, May 9-11, 1996.
13. Jain AK. Fertility reduction and the quality of family planning services. Stud Fam Plann 1989;20(1):1-16.

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