Defining the "Unmet Need" for Family Planning

Defining the "Unmet Need" for Family Planning

Ruth Dixon-Mueller and Adrienne Germain
When a woman tells an interviewer for a demographic survey that she is not practicing contraception even though she does not want to get pregnant and is at some risk of doing so, she can be said by some definitions to have an "unmet need" for family planning. The "need" in this case is defined not by the woman herself, but by the researcher who deduces it from the apparent inconsistency between her contraceptive behavior and reproductive preferences. Demographers have estimated the aggregate level of unmet need for family planning among women of reproductive age from national surveys taken in a number of Southern countries. These estimates have become an important policy tool for conceptualizing program strategies, estimating budgets and other resources needed, and assessing program outcomes.
It has not been easy to capture the elusive unmet need for family planning, however. It tends to hide from researchers and to change its size and shape depending on how survey questions are asked, what criteria are used, and what assumptions are made. It can grow or shrink quite dramatically from one survey to the next as the proportions of women hoping to delay or avoid pregnancy rise in response to changing family size norms, while lagging rates of contraceptive prevalence try more or less successfully to "catch up."
The net we have been using to stalk the elusive unmet need is also far too small. Many women escape it because of how the concept is defined and how the survey questions are asked. Other types of unmet need have not been captured at all in the conventional approaches. If the true extent of unmet need is to be reflected in policy making and program strategies, it is vital to obtain more comprehensive measures.

The Slipperiness of Conventional Estimates
Surveys conducted in a number of Southern countries since the mid-1970s, such as the World Fertility Surveys (WFS), Contraceptive Prevalence Surveys (CPS), and Demographic and Health Surveys (DHS), have stimulated some interesting efforts to measure women's unmet need for family planning at the national level. Such measures typically include all women of reproductive age who are married or in consensual unions and who say they want to postpone pregnancy by one or two years ("spacers") or to have no more children ("limiters") and yet are not using any contraceptive method (whether "modern" or "traditional"). Within this category, women who are pregnant or have not resumed menstruation following delivery, and those who appear incapable of conceiving, are usually excluded. Women who have not had sexual relations within the previous four weeks are also sometimes excluded because they are assumed not to be currently "at risk."
Some studies have identified those women who are currently pregnant or amenorrheic but said that their pregnancy was mistimed or unwanted as having an unmet need. Although this addition alters the time frame for calculating unmet need by referring back to the point of conception rather than to the woman's status at the time of the interview, it is important to recognize that some women are pregnant because their contraceptive needs were not met in the recent past.
Not surprisingly, the level of unmet need fluctuates widely according to the stringency of the definition being used. For example, an analysis of WFS data from 18 countries found that the average level of unmet need among married women who wanted no more children (that is, among limiters only) ranged from seven percent to 40 percent depending on which of 11 criteria were used. Including the unmet need among spacers and among women whose current pregnancies were mistimed or unwanted (neither of which was possible with WFS data) would produce higher estimates. On the other hand, adjusting for the effects of successful spacing on the unmet need for limiting would produce lower estimates from a somewhat different perspective.
The slipperiness of conventional estimates is not necessarily a problem, however, unless the results are misinterpreted, because each measure is useful for specific research and planning purposes. But restricting the concept of unmet need to nonusers of contraception who are at risk of an unwanted pregnancy obscures our vision of the true extent of women's (and men's) needs for family planning information and services in Southern countries. If we were to cast a larger net we would find that there is far more to the elusive unmet need than meets the eye.

Casting a Larger Net
Who might be included in an expanded definition of unmet need? Each of the following groups has special needs that deserve recognition by researchers, policy makers, and service providers:

Sexually active, unmarried women. Single, separated, divorced, and widowed women are excluded from most fertility surveys because researchers believe it is more difficult to inquire about their sexual and contraceptive behavior. Yet among 38 Southern countries included in the WFS, women spent an average 27 percent of their reproductive years in an unmarried state. Among the surveys that have included unmarried women, the 1987 CPS in Paraguay estimated that 33 percent of women who were married or in consensual unions had an unmet need for family planning, compared with 26 percent among the previously married and six percent among single women. A more realistic estimate of unmet need for family planning would include all sexually active, unmarried women, especially teenagers, who have difficulty obtaining the contraceptive advice and services they need.

Women with post-partum amenorrhea. Women who have not menstruated since their most recent birth are usually assumed not to need contraception. Yet women who are having sex could get pregnant before their periods resume. About seven percent of women in studies of several countries said they got pregnant before their menses returned. The risk of conceiving rises with shortened durations of breast feeding and with less frequent or intense feedings. Many amenorrheic women who are sexually active and do not want to get pregnant right away have an unmet need for contraception.

Women who are using a less effective contraceptive method but who definitely want to avoid or postpone childbearing. Some studies include such users as having an unmet need, but most do not. Yet contraceptive failure rates can be very high. In the Philippines, for example, 33 percent of couples relying on periodic abstinence (rhythm) and 44 percent of those using withdrawal got pregnant in the first year of practice. Without better information on how to improve the effectiveness of practices such as withdrawal or periodic abstinence, and without safe abortion as a backup, these couples' needs for effective birth control are not being met.

Women who are using a more effective method but who are using it incorrectly, are dissatisfied, or should not be using it for health reasons. Couples who are using a "modern" method incorrectly or sporadically (or even correctly) run some risk of accidental conception. Pregnancy rates per year among current users in the Philippines are about 60 percent for the condom, 20 percent for the pill, and four percent for the IUD. Women or their partners who are dissatisfied with a method because of side effects (real or imagined), inconvenience, or expense have an unmet need for better counseling and contraceptive choice, especially if they are otherwise likely to stop contracepting. Women who should not he using a particular method because of health contraindications have an unmet need for a safer method. The lack of appropriate medical screening and follow-up in many countries exacerbates this problem.

Women with unwanted pregnancies. WFS and DHS from 38 Southern countries found that 22 percent of married women (probably an underestimate) said their most recent pregnancy was unintended. Not all of these women would have terminated the pregnancy if they could have done so safely, of course, but more than two-thirds of women in Southern countries, excluding China, have no ready access to legal abortion. Surveys do not usually ask women about abortion because of underreporting. Yet every woman who would consider terminating an unwanted pregnancy or has tried to do so has an unmet need if she does not have access to safe and affordable abortion services.

Women with related reproductive health problems. Broadly defined, the term "family planning" refers not only to the ability to avoid childbearing when it is not wanted, but also to ensure childbearing when it is wanted. The diagnosis and treatment of infertility problems and their prevention through treatment of sexually transmitted diseases (STDs) would fall directly under this rubric. Women and men suffering from STDs and fertility impairments, who represent a large portion of the populations of reproductive age in some Southern countries, have significant unmet needs in this respect.

The Broader Scope of Unmet Need
The concept of unmet need has several layers. The first is the need among nonusers, who are at risk of an unwanted or untimely pregnancy, for any method of contraception. Even by this definition, the unmet need in some countries is substantial. Clearly, considerable program effort is required simply to reach those in need, both married and unmarried, especially in rural areas and among low-income groups. A second layer is the need among some users for a more effective, satisfactory, or safer method. These needs can be met by higher quality service delivery programs that offer clients a choice of contraceptive methods, empathetic counseling, careful medical screening and follow-up, and support for contraceptive continuation, combinations of methods, or switching. A third layer of need among both users and nonusers is for treatment of contraceptive failure (or nonuse), that is, for safe and accessible abortion services for the termination of mistimed or unwanted pregnancies. A fourth level consists of the need for related reproductive health services, such as infertility treatment and the prevention and treatment of STDs.
Many questions remain to be answered. Who are the women and men who are not served well by existing contraceptive methods and service programs? Are their unmet needs due primarily to the absence of appropriate technologies, to inadequate distribution of existing methods, or to inadequacies of service delivery systems in other respects? To what extent does the acceptability of contraception depend on the acceptability of specific modes of service delivery? What research approaches are best suited to inquiring about women's (and men's) attitudes toward contraceptive use and service delivery in different settings? The challenge for the 1990s is not only to meet the rising demand for contraception in general, but to serve better the needs of all people who are struggling to regulate or ensure their fertility.

This essay was reprinted and modified with the permission of The Population Council, from Ruth Dixon-Mueller and Adrienne Germain, "Stalking the Elusive 'Unmet Need' for Family Planning," Studies In Family Planning, Vol 23, No. 5, September/October 1992, pp. 330-335.

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