This post is part one of two in our family planning feature this week
A new article just released from scholars at Harvard School of Public Health highlights a very pertinent human rights and maternal health issue: unmet need for contraception. The article, Unmet Need for Contraception: Issues and Challenges by John Cleland, Sarah Harbison, and Iqbal H. Shah, reviews the history of family planning initiatives, strengths and weaknesses in measurement techniques for unmet need, lack of a male perspective in collecting contraceptive use data, levels and trends in unmet need, the relationship between access and unmet need, and program impact to reduce unmet need.
Trends in Unmet Need Around the World
The authors of this article explore both contraceptive prevalence rate (CPR) and unmet need prevalence globally and regionally. Overall, from 1970 to 2010 CPR has risen from 36% to 63% and unmet need has decreased from 22% to 12%.
However, when rates are assessed regionally, disparities appear. The regions with the most success over the last 40 years were Asia and Latin America and the Caribbean. They were able to more than double their CPR and decrease their unmet need from 24% in Asia and 28% in Latin America and the Caribbean in 1970 to 11% and 10.5% in 2010, respectively. In 2010, the lowest CPR (24%) and highest unmet need (25%) is currently in sub-Saharan Africa. Unfortunately, the rate of unmet need has seen little to no decline since 1970 in this region. These levels are similar to 1970 levels in Asia and Latin America and the Caribbean.
Likely due to China’s one-child policy, as of 2010, Eastern Asia is the world’s region with the lowest unmet need (4%) and highest CPR (82%). This region also had the most rapid increase in CPR and greatest decline in unmet need.
However, a rapid increase in contraceptive prevalence does not always conclude in a decrease in unmet need. In Pakistan, a drastic rise in CPR from 4% in 1970 to 33% in 2010 had little to no effect on prevalence of unmet need.
While the measurement of unmet need is somewhat complicated, unmet need is defined as the percentage of women who do not want more children for at least two years but are using no modern method of contraception. This article discusses and explores strengths and weaknesses to these methodologies.
There are reasons why current prevalence of unmet need may not reflect the needs of the population. As the authors state, “the major criticism of the concept of unmet need stems from the fact that it is imposed by analysts based on the discrepancy between future childbearing wishes and contraceptive use rather than from a direct expression of need by respondents.” Also, a large percentage of women who are included in those with an unmet need state that they do not plan to adopt contraceptives at any point in the future.
In addition, one trend that appears when assessing family planning, is that in some countries fertility is decreasing, yet unmet need remains. A reason why this may be true is that many women prefer periodic and other forms of abstinence to modern methods of contraceptives. For example, demographic and health surveys from Ghana show that well-educated women from Accra are more likely to use traditional methods than other women. Given the assumption that these well-educated women are making an explicit choice, the unmet need is overestimated in Ghana. However, in developing countries, 90% of contraceptive use is with modern methods, so including traditional methods in the contraceptive prevalence rate (CPR) may not make a notable difference.
Issues of Access and Unmet Need
Popular responses to addressing unmet need are to decrease distance to and cost of contraceptive access. However, these factors were determined as potential, but not great barriers to access. In contrast, what has been termed as psychosocial and information access seem to play a much more influential role in addressing unmet need. The most frequent reasons that women gave for not accessing modern contraception methods were infrequent sex and fear of side-effects. In addition, in Southern Asian and Western African countries, the authors stated that “social opposition by the respondent herself, the husband, and others were common reasons for not using contraception.
In conclusion, lack of knowledge—or partial and erroneous beliefs—concerning methods or services, together with social barriers, are key causes of unmet need in the early phase of family planning programs when contraceptive prevalence is low. The importance of these factors fades as time passes and use of modern methods becomes a familiar and commonplace part of life. Concerns regarding side effects and health, on the other hand, do not dissipate.”
Measuring Impact on Programs
In order to address the high unmet need in sub-Saharan Africa and the barriers to access that are often found there, the authors note Bongaart’s conclusion that information, education and communication (IEC) programs can reduce unmet need by 10% and increase CPR by 22% in low-use, high-unmet-need countries. This type of programming can be especially effective in these settings since social oppression and lack of knowledge have been identified as barriers to contraceptive use.
Are you addressing unmet need in your country? Have you had any successes or frustrations you would like to share with our MHTF audience? Please contact Katie Millar for guidance on submitting a guest post to our blog.