Special issue explores trends related to unmet need for contraception

June issue explores challenges in addressing unmet need for contraception, featuring research and case studies from Africa, Asia, and Latin America

NEW YORK, NY (16 June 2014) - Studies in Family Planning, a leading journal published by the Population Council, released "Unmet Need for Family Planning"-a special issue featuring ten articles, including a comprehensive introduction to the topic of unmet need. Distinguished researchers explore trends related to unmet need for contraception, and many articles point to practical strategies for increasing contraceptive knowledge and uptake, and for overcoming barriers that prevent women from practicing contraception.

"Unmet need has been an important indicator for measuring the progress of family planning programs for more than 25 years," said John Bongaarts, vice president and Distinguished Scholar at the Population Council. "This issue features work from some of the leading minds in family planning. It explores trends, identifies issues, and proposes solutions to ensure that sexual and reproductive health programs and policies are structured to meet the changing needs of women and men over the course of their reproductive lives."

The FP2020 goal of expanding family planning services to an additional 120 million women invites interest in exploring the reasons for nonuse of contraceptives among women with a desire to postpone or end childbearing (unmet need). The articles in "Unmet Need for Family Planning" advance understanding of these reasons by discovering cross-national as well as locally specific explanations that can aid efforts to improve family planning programs and reduce unintended pregnancy. The studies call attention to the importance of concerns regarding perceived side effects, use of less-effective methods of contraception, insufficient integration of family planning with other services, social pressure to bear children, and other important factors that may lead to suboptimal family planning practices.

The articles in the special issue represent updated versions of a selection of papers presented at an international seminar organized by the IUSSP (International Union for the Scientific Study of Population) in collaboration with the Population Council-led STEP-UP (Strengthening Evidence for Programming on Unintended Pregnancy) consortium, and AFIDEP (African Institute for Development Policy) in Nanyuki, Kenya in 2013. The Population Council extends its gratitude toward those participants who provided their insights and expertise during the seminar, as well as to the seminar organizers and guest editors of the special issue: John Cleland, Sarah Harbison, and Iqbal H. Shah. Financial support for the seminar was generously provided by USAID, DFID, the Wellcome Trust, and WHO.

The full table of contents and a synopsis of each article are included below. All of the articles in "Unmet Need for Family Planning" are available online, free of charge.

Introduction and Overview

1. Unmet Need for Contraception: Issues and Challenges (John Cleland, London School of Hygiene and Tropical Medicine; Sarah Harbison, USAID; and Iqbal H. Shah, Harvard School of Public Health)

This article provides a broad context for the contributions that follow in this special issue. Validity and measurement of unmet need are discussed. Regional trends among married women since 1970 are also presented. Major reductions in unmet need have been achieved, with the clear exception of sub-Saharan Africa. Less success can be claimed in addressing the needs of sexually active unmarried women, who contribute nearly 20 percent to overall unmet need in developing countries. Prominent reasons for unmet need in settings where contraceptive uptake is low include social resistance and insufficient information concerning methods. As contraceptive use increases, the importance of these reasons wanes, but concerns regarding side effects and health impact remain a barrier, and discontinued users now constitute a large proportion of those with unmet need. Drawing on these reasons, the authors outline measures to reduce unmet need.

2. Understanding Unmet Need: History, Theory, and Measurement (Sarah E.K. Bradley, ICF International; and John B. Casterline, Ohio State University)

This article recounts the evolution of the concept of unmet need, describes how demographic survey data have been used to generate estimates of its prevalence, and tests the sensitivity of these estimates to various assumptions in the unmet need algorithm. The sensitivity tests suggest that alternative criteria for identifying four out of five subgroups of women would increase the estimated prevalence of unmet need. The exception is identification of married women who are sexually active; more accurate measurement of this subgroup would reduce the estimated prevalence of unmet need in most settings.

Unmet Need, Contraceptive Use, and Fertility

3. Reasons for Contraceptive Nonuse among Women Having Unmet Need for Contraception in Developing Countries (Gilda Sedgh and Rubina Hussain, Guttmacher Institute)

This study draws upon data from 51 surveys conducted between 2006 and 2013 in Africa, Asia, and Latin America and the Caribbean to provide an updated review of the reasons why many married women with unmet need are not practicing contraception. The authors examine the reasons for contraceptive nonuse and how these reasons vary across countries and according to national levels of unmet need and contraceptive use. Findings suggest that access to a range of methods, and information and counseling, can be critical in helping women overcome obstacles to contraceptive use.

4. Do Natural Methods Count? Underreporting of Natural Contraception in Urban Burkina Faso (Cl-mentine Rossier, University of Geneva and Institut National d'Etudes D-mographiques, Paris; Leigh Senderowicz and Abdramane Soura, Institut Sup-rieur des Sciences de la Population, University of Ouagadougou, Burkina Faso)

Natural methods of contraception were widely used in developed countries until the late 1960s to space and limit childbirth. The Demographic and Health Surveys do not currently include questions specific to natural methods. The authors analyzed data from a 2010 health survey conducted in Ouagadougou, Burkina Faso, among 758 women aged 15�� in which the standard DHS question regarding current contraceptive use was expanded to elicit fuller responses regarding use of natural methods. The expanded survey instrument enabled the researchers to find a notable increase in the proportion of women in union who reported practicing contraception. Many women classified as having unmet need for family planning in Ouagadougou by the DHS are in fact users of natural methods. The authors conclude that additional questions measuring use of natural methods more completely should be tested in different settings.

5. Demand for Contraception to Delay First Pregnancy among Young Married Women in India (Shireen J. Jejeebhoy, K.G. Santhya, and A.J. Francis Zavier, Population Council)

In India, evidence is sparse regarding the demand for contraception to delay first pregnancy among married young people. Using data drawn from a study conducted in six Indian states among 9,572 women aged 15�� who were married for five or fewer years, the authors explore the scope of this demand, the extent to which it has been satisfied, and, using logistic regression analyses, the factors associated with contraceptive use to delay first pregnancy. Findings confirm considerable demand for contraception to postpone first pregnancy (51 percent). Of those with demand, only 10 percent had practiced contraception. Contraception was more likely to have been practiced by educated women, those aware of family planning methods before they were married, those exposed to quality sexuality education, and those who participated in marriage-related decision making. Women who reported feeling pressure to prove their fertility were less likely to have practiced contraception.

6. Unmet Need for Family Planning in Ghana: The Shifting Contributions of Lack of Access and Attitudinal Resistance (Kazuyo Machiyama and John Cleland, London School of Hygiene and Tropical Medicine)

In Ghana, despite a 38 percent decline in the total fertility rate from 1988 to 2008, unmet need for family planning among married women declined only modestly during this period. Examining data from the five DHS surveys in Ghana during these years, researchers found that the relative contribution to unmet need of lack of access to contraceptive methods has diminished, whereas attitudinal resistance has grown. An enduring resistance to hormonal methods, much of it based on prior experience of side effects, may lead many Ghanaian women, particularly the educated in urban areas, to use periodic abstinence or reduced coital frequency as an alternative to modern contraception.

7. Unmet Need and Fertility Decline: A Comparative Perspective on Prospects in Sub-Saharan Africa (John B. Casterline, Ohio State University; and Laila O. El-Zeini, American University in Cairo, Egypt)

This study assesses how changes in unmet need for family planning have contributed to contemporary fertility declines, and the implications of this historical record for further fertility decline, especially in sub-Saharan Africa. Researchers examined joint trends at the national level in fertility, unintended fertility, and unmet need. The association over time between unmet need and fertility is investigated using survey data from 45 countries in Africa, Asia, and Latin America and the Caribbean from the mid-1970s to the present. The empirical analysis reveals that reduction in unmet need, especially need for limiting pregnancies, is strongly associated with fertility decline in Latin America and the Caribbean and in Asia and North Africa. Fertility decline in sub-Saharan Africa, by contrast, is weakly associated with trends in unmet need (and satisfaction of demand). The authors propose that the marked regional difference is due to measurement problems and to the different character of fertility decline in sub-Saharan Africa.

Reducing Unmet Need

8. The Impact of Family Planning Programs on Unmet Need and Demand for Contraception (John Bongaarts, Population Council)

Much of the existing literature on the demographic impact of family planning programs focuses on their role in increasing contraceptive use, which, in turn, accelerates fertility decline. What is not clear, however, is whether this effect operates solely through a reduction in unmet need brought about by eliminating obstacles to use or whether and to what extent the programs also affect demand for contraception through messages concerning the benefits of family planning. This article attempts to shed light on this issue by analyzing data drawn from recent Demographic and Health Surveys conducted in 63 developing countries. The first section reviews general levels and trends in unmet need, demand, and use over the course of the fertility transition. The second section presents different types of evidence of program effects, including results from a controlled experiment and from country case studies. The evidence indicates a program impact on both unmet need and demand.

9. Using Measurements of Unmet Need to Inform Program Investments for Health Service Integration (Shawn Malarcher and Chelsea B. Polis, USAID)

Demographic and Health Survey (DHS) data could potentially inform optimal strategies to reach women having unmet need with contraceptive services through integrated service delivery. The authors examined DHS data from Nepal, Senegal, and Uganda and identified substantial missed opportunities to reach married or cohabitating women of reproductive age (MWRA) having unmet need. Between 4 percent and 57 percent of MWRA having unmet need in these countries could be reached through integration of FP into any single-service delivery platform that the authors explored. This analysis has the potential to provide program managers with an evidence-based road map indicating which service-delivery platforms offer the greatest potential to reach the largest number of women.

10. Reducing Unmet Need and Unwanted Childbearing: Evidence from a Panel Survey in Pakistan (Anrudh K. Jain, Zeba A. Sathar, and Irfan Masood, Population Council; Arshad Mahmood, Director of Monitoring and Evaluation of the FALAH Project at the time the study was conducted)

Pakistan's high unmet need for contraception and low contraceptive prevalence remain a challenge, especially in light of the country's expected contribution to the FP2020 goal of expanding family planning services to an additional 120 million women. The author's analysis of panel data from 14 Pakistani districts suggests that efforts to reduce unmet need should also focus on empowering women to achieve their family planning goals through continuation of any method of their choice. Providing women with better quality of care and encouraging method switching would bridge the gap that exists when women are between methods and thus would reduce unwanted births. This finding is generalizable to other countries that, like Pakistan, are highly dependent on short-acting modern and traditional methods. The approach of preventing attrition among current users would be as effective as encouraging nonusers to adopt a method for the first time.