PRB

As more evidence about the health and economic benefits of family planning becomes available, global and national stakeholders are paying more attention to addressing the reproductive health needs of women and couples through family planning. Family planning results in healthier children and mothers through promoting appropriate timing between births. And family planning ultimately contributes to economic growth: When populations grow more slowly as a result of family planning, parents have the opportunity to invest more in the health and education of their children. Yet, even when women do not want to have more children or want to wait to have another child, many of them are not using effective methods of family planning; these women have an “unmet need” for family planning. Although women can have their family planning needs met at one point in time, they may face unmet need later for a variety of reasons, including changes in their relationships or fertility plans, or because they discontinue using their current contraceptive method. Because a woman’s need for family planning changes over her life, unmet need for family planning is best thought of as being in a state of flux based on a woman’s circumstances at a given point in time.

Global advocacy and development initiatives, including the recent 2012 London Summit on Family Planning, are highlighting the importance of reaching women who have an unmet need for family planning with information and services that will enable them to space their pregnancies and achieve their desired family size.

Understanding Unmet Need

Unmet need is defined in two ways: unmet need for limiting childbearing and unmet need for spacing childbearing. Unmet need for limiting childbearing is the proportion of currently married women who do not want any more children but are not using an effective form of family planning. Unmet need for spacing childbearing is the proportion of currently married women who want to postpone their next birth for two years or more but are not using an effective family planning method.¹ Thus, unmet need gives an estimate of the proportion of women who are potential users. Around the world, about 222 million women have an unmet need for family planning, and 645 million women have their needs met through the use of a modern contraceptive method such as IUD, pill, injectables or sterilization.² When the number of women with unmet need is added together with women who are already using family planning (“met need”), the total is referred to as the total demand for family planning.

Reasons for Unmet Need Vary by Region

Estimates of unmet need can offer information about family planning efforts, but must be put into context. A country may have high unmet need for a variety of reasons, including limited financing for commodities and services and a poor logistics system that prevents family planning commodities from getting to providers. However, many women choose not to use family planning for other reasons as well: side effects, health concerns, cultural and religious objections, lack of knowledge, and objections from a spouse.³

As shown in the figure, the reasons vary according to geographic region. In sub-Saharan Africa, the leading reasons are concerns about adverse health effects and side effects and opposition by the woman or her partner. In South Central Asia, one in three women said that she or her partner opposed use of family planning; in contrast, in Southeast Asia, almost four in 10 women did not use an effective method because they were concerned about their health and the method’s side effects. Across the three regions, no access and high cost represented a relatively small proportion of the reasons for not using contraception.⁴

Health Concerns and Opposition to Family Planning Are Leading Reasons That Women Do Not Use Modern Contraception, Even Though They Want to Avoid Becoming Pregnant.

Source: Jacqueline E. Darroch, Gilda Sedgh, and Haley Ball, Contraceptive Technologies: Responding to Women’s Needs (New York: Guttmacher Institute, 2011).

Because unmet need is context specific and responsive to changing cultural norms, high levels of unmet need do not necessarily mean that family planning efforts are not working (see table). As countries transition from high fertility to low fertility, unmet need will initially be low (as seen in Niger), then increase in response to more knowledge about family planning and changing norms (as in Uganda). Finally, unmet need can reach a low level because women who want to use family planning are doing so, and relatively few women who want to space or limit childbearing are not using a method.

Unmet Need for Family Planning Should Be Considered in the Context of Family Planning Program and Fertility Indicators

* Average, married women.
Source: ICF Macro, various DHS country reports.

Low levels of unmet need can also reflect a desire for large families, which leads women to have very little interest in spacing or limiting childbearing. As shown in the table, in Niger, traditional norms for large families lead to low use of modern contraception, as well as a low unmet need because women have an average ideal family size of more than nine children. In Uganda, contraceptive use is relatively low, but increasingly, women want fewer children, thus leading to a higher level of unmet need. Use of contraception in Nepal is relatively high, yet unmet need for spacing is high among young women who want to postpone a pregnancy but are often afraid that the contraceptives will make them infertile. Finally, Colombia’s mature family planning programs and a cultural norm for smaller families result in very high contraceptive prevalence and low unmet need.

Characteristics of Women With Unmet Need

Sub-Saharan Africa has the highest percentage of women with unmet need: Approximately 25 percent of women in the region—some 49 million women—either use traditional methods or no method at all, yet they wish to avoid pregnancy. The unmet need for spacing births is much greater in this region than for limiting births: 16 percent vs. 9 percent, respectively. Although unmet need is much lower in South Central Asia (16 percent) because of the large population in the region, the number of women with unmet need is approximately 71 million. In contrast to sub-Saharan Africa, unmet need for limiting births is greater than for spacing births in South Central Asia: 9 percent vs. 7 percent, respectively.⁵

But averages hide much of the variation found within a region. For example, in sub-Saharan Africa, unmet need is as low as 13 percent in Zimbabwe (where 58 percent of married women use a modern method) to as high as 41 percent in Togo (where only 12 percent of women use a modern method). In Asia, Laos reported the highest level of unmet need (40 percent) and Vietnam reported the lowest (5 percent).

Because use of contraception tends to be higher among wealthier women, unmet need is usually higher among poorer women. In Ethiopia, poor women reported an unmet need of 32 percent, compared to 15 percent among wealthy women. Bolivia reported a similarly large gap: 34 percent among poor women and 10 percent among wealthy. However, this pattern does not always hold. For example, in the Democratic Republic of Congo, 27 percent of poor women and 28 percent of wealthy women reported unmet need. Liberia had a similar pattern: 33 percent of poor women had an unmet need, as did 31 percent of wealthy women. And a third pattern, suggesting a shift in norms for large ideal family size among the wealthy, is demonstrated by Niger, where unmet need was 21 percent among wealthy women and only 16 percent among poor women. This pattern suggests that as wealthier women begin to want smaller families, they will increasingly want to use family planning and will likely overcome existing barriers to using it.

Just as unmet need must be interpreted in light of other indicators—contraceptive prevalence, total fertility rates, ideal family size and preference, and method mix—the reasons for not using effective family planning methods can guide program efforts to improve the uptake of modern methods.

James N. Gribble is vice president of International Programs at the Population Reference Bureau.

References

1. Charles Westoff, “New Estimates of Unmet Need and the Demand for Family Planning,” DHS Comparative Reports 14 (2006).
2. Susheela Singh and Jacqueline Darroch, Adding It Up: Costs and Benefits of Family Planning Services, Estimates for 2012 (New York: Guttmacher Institute, 2012).
3. Samuel Mills, Ed Bos, and Emi Suzuki, Unmet Need for Contraception (Washington, DC: World Bank, 2010).
4. Jacqueline E. Darroch, Gilda Sedgh, and Haley Ball, Contraceptive Technologies: Responding to Women’s Needs (New York: Guttmacher Institute, 2011).
5. Donna Clifton, Toshiko Kaneda, and Lori Ashford, Family Planning Worldwide 2008 Data Sheet (Washington, DC: Population Reference Bureau, 2008).