(July 2012) The widespread adoption of family planning represents one of the most dramatic changes of the 20th century. The growing use of contraception around the world has given couples the ability to choose the number and spacing of their children, which, in turn, has prevented large numbers of unintended pregnancies, reduced the number of abortions, and reduced the incidence of deaths and illnesses related to pregnancy and childbirth. In addition to the tremendous health benefits, fewer, well-spaced children have enabled women to participate more in household income-generating tasks and community activities, promoting women's empowerment and gender equity. Yet despite all of these impressive gains, contraceptive use is still low and the need for contraception is high in some of the world's poorest and most populous places.

It's against this backdrop that new global advocacy and development initiatives, including the 2012 London Summit on Family Planning, are drawing attention to the plight of women who, regardless of family planning program advancements, are still encountering serious barriers to contraceptive use. Understanding who these women are—the often silent "faces of unmet need"—and the reasons why their need is not satisfied, can help us better understand how to bring an end to this ongoing challenge.

Changing Needs Across a Woman's Reproductive Life

Today, more than 220 million women in developing countries report having an unmet need for family planning at different stages of their reproductive lives.1 These are women, either married or unmarried, who are sexually active and say that they want to postpone their next birth by at least two years, or not have any more children at all, but they are not using any type of contraceptive method.2 This huge number of women in need looms large in stark contrast to women in developed countries, many of whom never experience serious obstacles to obtaining family planning counseling and services.

Meeting the contraceptive needs of women reflects a complex range of processes that make up a woman's set of choices and challenges over her reproductive life. To achieve their desired family size and avoid unintended pregnancies, women will spend the majority of their childbearing years in need of contraception. For example, women who want four children will spend an estimated four years trying to get pregnant, three years actually being pregnant, two years in the postpartum period unable to get pregnant, and 16 years trying to avoid a pregnancy.3 If a woman only wants two children, the number of years she needs to avoid a pregnancy rises to almost 21 years of her reproductive life!

The need for contraception, and the type of method needed, is also likely to change over a woman's life course. She may move from using a traditional method to a modern method; from using a short-term method (pills, injectables, condoms, or vaginal methods) to a long-term (IUDs or implants) or permanent method (sterilization or vasectomy); or she may have gaps between methods (because she is pregnant or postpartum or wants a child). In addition, shifts in preferences for having a child or in the timing of having a child often occur in response to changing life circumstances such as entering a serious relationship, attaining the level of education desired, or changes in household finances.

The complexity of the issue underscores two important points: The transitional nature of the need for family planning can pose serious challenges for women and their partners' ability to control their reproductive lives— especially in countries where social and cultural barriers are prevalent and services are less available; and understanding these transitions enhances our ability to better meet couples' contraceptive needs.

Where Are the Women With Unmet Need?

Sub-Saharan Africa has the highest percentage of women with unmet need—approximately one out of every four women of reproductive age in the region or about 47 million women.4 In South Central Asia and Southeast Asia, the proportion of women with unmet need is lower at 18 percent and 14 percent, respectively. However, although Asia has lower proportions of women with unmet need, the size of the population is larger than in other regions. As a result, more than 100 million women in South Central and Southeast Asia have an unmet need.5 Latin America and the Caribbean have the lowest proportion—only one out of 10 women have an unmet need for contraception.6

Levels of unmet need vary greatly among women with different characteristics. In general, unmet need is highest among those women who face financial, educational, geographic, or social barriers to obtaining family planning services. For example, in some countries in Latin America the poorest 20 percent of women are twice as likely to have unmet need compared to the wealthiest 20 percent of women.7 Unmet need also varies with age. In sub-Saharan Africa, South Central Asia, and Southeast Asia, more than two-thirds of women younger than 20 who want to avoid a pregnancy have an unmet need for family planning.8

What Are the Reasons for Unmet Need?

There is a general belief that the primary reason for women not using contraceptives is because family planning services are not available or because it is too expensive. But this is only part of the story. There are many reasons why women don't use contraceptives and they vary across the regions. In sub-Saharan Africa, the leading reasons are concerns about adverse health effects and side effects of contraceptives and the fact that they are breastfeeding. About one in six women in Africa believes, often incorrectly, that they cannot get pregnant if they are breastfeeding. In South Central Asia, the leading reason for not using was that she or her partner opposed the use of family planning, while in Southeast Asia, women gave concerns about health and side effects as the primary reason for not using an effective method. Across the three regions, no access and cost of family planning services represented a relatively small proportion of the reasons for women not using contraception, ranging from 6 percent to 11 percent.9

Contraceptive supply also plays a role in the level of unmet need. In a recent study on the availability of contraceptives in sub-Saharan Africa, 12 out of 16 countries surveyed reported central store stockouts of one or more contraceptives over a 12-month period.10 In many African countries, particularly in rural areas, long-term and permanent methods of family planning are not available.

What Do We Need to Do?

We need to ensure that the contraceptive needs of all women—young and old, married and unmarried, poor and wealthy, rural and urban—are met. Meeting the family planning needs of all women means reducing inequities in knowledge, overcoming social and cultural barriers, and ensuring access to high-quality services. Together, we can make sure that no woman has to face an unmet need.


Rhonda Smith is associate vice president of International Programs at PRB.


References

  1. Susheela Singh and Jacqueline Darroch, Adding It Up: Costs and Benefits of Contraceptive Services, Estimates for 2012 (New York: Guttmacher Institute, 2012).
  2. Singh and Darroch, Adding It Up.
  3. Jacqueline Darroch, Gilda Sedgh, and Haley Ball, Contraceptive Technologies: Responding to Women's Needs (New York: Guttmacher Institute, 2011).
  4. Darroch, Sedgh, and Ball, Contraceptive Technologies.
  5. Darroch, Sedgh, and Ball, Contraceptive Technologies.
  6. Facts on Satisfying the Need for Contraception in Developing Countries (New York: Guttmacher Institute and IPPF, 2010).
  7. John Cleland et al., "Family Planning: The Unfinished Agenda,"The Lancet 368, no. 9549 (2006): 1810–27.
  8. Darroch, Sedgh, and Ball, Contraceptive Technologies.
  9. Darroch, Sedgh, and Ball, Contraceptive Technologies.
  10. USAID | DELIVER PROJECT, Task Order 1, Contraceptive Security Indicators Data 2010.