# Unmet need for family planning

Unmet need for family planning

# Unmet need for family planning

The number or percent of women who are sexually active, currently married or in union who are fecund and who desire to either terminate or postpone childbearing, but who are not currently using a contraceptive method.

The total number of women with an unmet need for family planning (FP) consists of two groups of women: (a) those with an unmet need for limiting, including childless women who don’t want to ever have children and (b) those with an unmet need for spacing. The indicator is often calculated for women with an unmet need for modern contraceptive methods. Current marital/union status is often used as a proxy for sexually active.

Women with an unmet need for limiting are those who desire no additional children and who do not currently use a (modern) contraceptive method. Women with an unmet need for spacing are those who desire to postpone their next birth by a specified length of time (for example, for at least two years from the date of a survey) and who do not currently use a (modern) contraceptive method.

This indicator is calculated as follows:

UL+ US = U

Where:
U = the number or percent of women with unmet need for (modern) FP;
UL = the number or percent of women with an unmet need for limiting; and
US = the number or percent of women with an unmet need for spacing.

Illustrative Computation:

Estimate of unmet need for FP, Bangladesh, 2017-18 (expressed as the percentage of women currently married or in union).

UL + US = U
6.6 + 5.4 = 12.0
Source of data: Bangladesh Demographic and Health Survey, 2017-18

Note: The actual calculation of unmet need is fairly involved, as depicted in the United Nations Population Division’s 2019 Metadata on Unmet Need. A common misconception is that unmet need is measured simply by asking women if/when they want to become pregnant and if they are using contraception. In fact, calculating unmet need is extremely complex and is measured using more than 15 different survey questions.

Responses to survey questions on:

• Current contraceptive use status;
• Desire for additional children and, if so, the desired length of birth interval;
• Current fecundity, pregnancy, and amenorrhea status for women not currently using a contraceptive method;
• The planning status (with respect to number and/or timing) of the current/last pregnancy for women currently pregnant or amenorrheic;
• Use (or not) of a contraceptive method at the time of the current/last pregnancy; and
• Whether sexually active if calculated for unmarried women. (The Demographic and Health Survey (DHS) defines sexually active as sex within the 30 days prior to the survey.)

Population-based survey

This indicator provides information on the size of an extremely important population sub-group for FP program management: women at risk of pregnancy with an apparent need for FP services based upon their expressed desire to limit or space future births and their non-use of (modern) contraception. Such women are considered to have an “unmet demand” or “unmet need” for FP and are a primary audience of program efforts.

The indicator may also be interpreted as the percentage (or number) of additional clients who would be using (modern) contraception over and above the number of current users, if all women at risk of pregnancy and desiring to prevent, terminate or postpone childbearing were to adopt contraception. However, this interpretation provides a hypothetical maximum percentage or number, as not all women at risk of unplanned or unwanted pregnancy who are non-users of (modern) contraception would choose to use (modern) contraception, even with high-quality fully accessible FP services (see issues and challenges below).

The indicator follows from the breakdown of total demand for FP services into two components: “demand satisfied” and “unmet demand” (or “unmet need”). Demand satisfied consists of women who are using a contraceptive method to achieve their reproductive goals; unmet need, or unmet demand, consists of women with an apparent demand for FP who are not using contraception.

A related indicator, the demand for FP satisfied with modern methods, is used to monitor progress of Sustainable Development Goal 3 and consists of the percentage of total demand for FP satisfied by current modern contraceptive use. Thus:

Satisfaction of demand for FP met with modern methods = modern contraceptive prevalence rate (mCPR) / (CPR + unmet need)

Using an example from the Kenya 2022 DHS, if unmet need for currently married women is 13.9, mCPR is 56.9 and CPR is 62.5, the percent of demand for FP satisfied with modern methods is 74.5%:

(56.9 / (62.5+13.9)) x 100 = 74.5%

Although unmet need for contraception has been a central indicator for monitoring the progress of FP programs for the past 30 years, its measurement contains numerous assumptions and imprecisions (Cleland, Harbison and Shah, 2014). One challenge pertains to whether unmet need is assessed for married women only, or if it is also assessed for unmarried women and all sexually active women of reproductive age. Refining the population of interest is particularly relevant for countries in which a significant share of childbearing occurs outside of recognized marriages/unions.

Another concern about this indicator is that it does not necessarily decrease linearly when FP programs improve and desired fertility decreases; improvements in FP programs can actually increase demand for contraception methods and services beyond the existing supply. As a result, estimates of unmet need will rise until supply shifts to meet the new demand (Bongaarts, 1991). This curvilinear relationship between unmet need and program strength (as proxied by CPR), which has been noted in the literature from early in the formulation of the unmet need concept, renders it necessary to use unmet need and contraceptive prevalence measures jointly to effectively capture the intersection of FP policies and practices. In the longer term, unmet need declines and this progressive satisfaction of need through, for instance, better access to services of higher quality, remains the main driving force behind increasing CPR (and both falling fertility and reduced recourse to abortion) (Becker, et al., 2006).

Additional challenges identified in the literature include the following:

• The concept of unmet need is based on the discrepancy between future childbearing wishes and contraceptive use rather than from a direct expression of contraceptive need by respondents (Cleland, Harbison, and Shah, 2014). Non-users at risk of unwanted pregnancy often cite contraceptive side effects and health risks, opposition to contraception, infrequent sexual activity, and breastfeeding status, as reasons for their non-use (Hussain, Sedgh, and Ashford, 2016). As a result, unmet need has been found to have low sensitivity and specificity in differentiating individuals who lack access to FP and/or who desire to use a method from individuals who do not (Senderowicz et al., 2023). Some researchers have called for a change in label for the indicator to “potential demand” or “utilization gap” to avoid the implication that women “need” or “demand” to use contraception (Speizer et al., 2022).
• Users of traditional methods are treated as non-users based on the implicit assumption that they lack access to, or information concerning, more effective methods.
• For married or cohabitating women, no allowance in the measurement of unmet need is made for sexual abstinence.
• Nearly all unmet need estimates are based exclusively on reports by women. When the male perspective is considered, husbands typically are more likely than wives to report FP use.
• Not all users of modern contraceptives have their specific needs met with the method they are currently using; this subpopulation should also be prioritized for FP services (see Rominski & Stephenson, 2019).

(Excerpted from: Becker L, Wolf J, Levine R (2006) Measuring commitment to health. Center for Global Development.)

By decreasing unmet need, governments will also decrease unwanted pregnancies, which occur disproportionately among the poor and may have a significant impact on poverty status. An examination of unwanted fertility rates in low-income countries found that in more than three-quarters of the countries, the poorest quintile experienced a higher unwanted fertility rate than the wealthiest (Gelband H, et al. 2001). In many cases, the difference between the two is substantial.

Unwanted pregnancies often tend to be higher risk, particularly among women at the extremes of the fertile age spectrum. Unwanted pregnancy is strongly associated with maternal mortality through unsafe abortion and pregnancy complications involved with high-risk factors (Klima, 1998). Some evidence suggests that the children who are the products of unwanted pregnancies experience negative outcomes later in life (Marston & Cleland, 2003). In addition to the mortality effects of unintended pregnancy, it also can limit educational opportunities for the mother, and can strain household finances. All of these factors collectively can impact the poverty status of the whole family in both the short and the long term (Gelband, et al., 2001).

A gender-sensitive approach to unmet need, or the contraceptive use gap, would examine which factors lead to unmet need, distinguish between the unmet need of women and men, and include gender-sensitive service-delivery strategies.

1. Gender considerations that may lead to unmet need:

• Do women and men have different access to the knowledge and household resources that would enable them to use FP effectively?

• Do women and men have different levels of decision-making autonomy and freedom of movement that would enable them to use FP effectively?

• Do women and men have the communication skills to discuss their fertility and FP preferences with their partners?

• Is FP use a factor in gender-based violence, actual or feared?

• To what extent are fertility preferences shared between women and men?

• Are cultural norms regarding extramarital sexual relations different for women and men, and the expectations of bearing children with different sexual partners?

• In societies with polygamous unions, how do women and men view childbearing?

• Is son preference a dominant issue in different fertility preferences between women and men?

2. Gender considerations that may affect unmet need from a service-delivery perspective:

• Are providers trained to recognize gender-based obstacles to effective use of FP (e.g., women clients may find it difficult to ask questions)?

• Are providers trained to screen for gender-based violence?

• Do providers’ own gender-based cultural norms and biases contribute to unmet need, (e.g., unmarried women or widows should not be having sex, but it is okay for young men and widowers)?

• Does the service-delivery system include strategies to mitigate gender-based financial or access constraints? Are services available at times and places convenient to female and male clients?

Becker L, Wolf J, Levine R (2006) Measuring commitment to health. Center for Global Development.

Bongaarts, J. 1991. “The KAP-Gap and the Unmet Need for Contraception.” Population and Development Review 17, 2: 293-313.

Cleland J, Harbison S and Shah IH. 2014. “Unmet Need for Contraception: Issues and Challenges.” Studies in Family Planning 45(2): 105-122.

Gelband H, et al. 2001. “The Evidence Base for Interventions to Reduce Maternal and Neonatal Mortality in Low and Middle-Income Countries”. Geneva, Commission on Macroeconomics and Health Working Paper Series. WHO Commission on Macroeconomics and Health. http://www.cmhealth.org/docs/wg5_paper5.pdf

Hussain R, Sedgh G, Ashford LS. 2016. “Unmet Need for Contraception in Developing Countries: Examining Women’s Reasons for Not Using a Method, New York: Guttmacher Institute. https://www.guttmacher.org/report/unmet-need-for-contraception-in-developing-countries

Klima C. 1998. “Unintended Pregnancy: Consequences and Solutions for a Worldwide Problem.” Journal of Nurse-Midwifery 43.6: 483.

Marston C & Cleland J. 2003. “Do Unintended Pregnancies Carried to Term Lead to Adverse Outcomes for Mother and Child? An Assessment in Five Developing Countries.” Population Studies 57.1: 77-93.

Senderowicz,L, Bullington BW, Sawadogo N, Tumlinson K, Langer A, Soura A, Zabré P, Sié A. 2023. “Assessing the suitability of unmet need as a proxy for access to contraception and desire to use it.” Studies in Family Planning 54(1). https://doi.org/10.1111/sifp.12233

Speizer IS, Bremner J, Farid S, FP2030 Performance Monitoring and Evaluation Working Group. 2022. “Language and measurement of contraceptive need and making these indicators more meaningful for measuring fertility intentions of women and girls.” Global Health: Science and Practice. https://www.ghspjournal.org/content/10/1/e2100450

United Nations Population Division/DESA: Fertility and Family Planning Section. World Contraceptive Use 2019: Unmet Need for Family Planning. https://www.un.org/en/development/desa/population/publications/dataset/contraception/wcu2019.asp

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