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HOME: STATE OF WORLD POPULATION 2004: Reproductive Health and Family Planning
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Reproductive Health and Family Planning

Family Planning and Sexual Health
Contraceptive Access and Use
Unmet Need
Choice of Methods
Sexually Transmitted Infections
Quality of Care
Stronger Voices for Reproductive Health
Securing the Supplies
Men and Reproductive Health

Unmet Need

Unmet need refers to women and couples who do not want another birth within the next two years, or ever, but are not using a method of contraception.(5) Unmet need results from growing demand, service delivery constraints, lack of support from communities and spouses, misinformation, financial costs and transportation restrictions.

The ICPD gave priority to reducing unmet need as a guiding principle in ensuring births by voluntary and informed choice.(6) The United Nations’ 1999 review of implementation progress adopted benchmark indicators: reduction of unmet need to half of 1990 levels by 2005 and satisfaction of all stated fertility desires by 2015.(7)

The ability of people to implement their family size and spacing desires is a matter of great personal and demographic importance. In developing countries, total fertility regularly exceeds what people report as wanted fertility; on average the difference is around 0.8 children.(8) As family size desires shrink, unmet need tends to grow until service capacity catches up with the demand for fewer births and longer birth intervals. After that, further gains in service accessibility successively reduce unmet need.(9)

SUBSTANTIAL GAPS—AND GROWING. Despite the increase in contraceptive prevalence, some 137 million women still have an unmet need for contraception(10) and another 64 million are using traditional family planning methods that are less reliable than modern methods.(11) Overall, 29 per cent of women in developing countries have an unmet need for modern contraception. The highest proportion, several times the level of current use, is in sub-Saharan Africa where 46 per cent of women at risk of unintended pregnancy are using no method.(12)

Barriers to contraceptive use include:

  • Lack of accessible services, and shortages of equipment, commodities and personnel;

  • Lack of method choices appropriate to the situation of the woman and her family;(13)

  • Lack of knowledge about the safety, effectiveness and availability of choices;

  • Poor client-provider interaction;(14)

  • Lack of community or spousal support;

  • Misinformation and rumours;

  • Side-effects for some, and insufficient follow-up to promote method switching or ensure proper use and dosage;

  • Financial constraints.

Young people are particularly affected by a lack of temporary methods, inadequate confidentiality and privacy, and providers’ lack of sensitivity to their perspectives.(15)

Despite decades of work to reduce these constraints, many problems persist. The decline of health systems in many countries has reduced access to services and the quality of personnel. Reduced donor support and inadequate national investments have hurt programmes. User fees, meant to promote sustainability and lower public sector costs, have increased inequities. Low salaries and poor working conditions lead employees to leave public health services for the private sector, further restricting access to the poor while driving the near-poor into poverty.

In 1999, at least 300 million married women lacked access to pills, IUDs or condoms.(16) Including voluntary sterilization, nearly 400 million lacked a full range of contraceptive choices. Since then, national reports show progressive improvements in the availability of multiple contraceptive methods.

Figure 3 shows the relationship between contraceptive use (including traditional methods) and unmet need, based on survey data from the past decade. The expected pattern is clearly evident: unmet need is highest in countries where prevalence is between 25 and 40 per cent.

Figure 3: Unmet need and total prevalence

Click here to enlarge image

Click here to enlarge image

Source: Data provided by K. Johnson, ORC MACRO, International, from Demographic and Health Surveys.

Increases in modern method use generally reduce unmet need. At low levels of modern method use, unmet need varies greatly, depending on the level of unsatisfied demand and the degree to which people turn to available traditional methods before modern contraceptive services are available.

POVERTY AND DESIRED FAMILY SIZE. Poorer people tend to want more children than richer people.(17) Parents may see advantages in having more hands for subsistence farming, for example, or hope to ensure that they will have surviving children in their old age. Constrained opportunities also make the poor less likely to find social and economic incentives to invest more in fewer children rather than shallowly in many.(18)

But even in poor families, stated family size desires have been declining for decades, despite the persistence of attitudes and traditions favouring larger families. This is reflected in high levels of unmet need among the poor. There is much less difference between poorer and richer people with regard to wanting to postpone or avoid another birth than in contraceptive use.

The proportion of demand met by modern family planning rises steadily as modern use increases. In all cases, richer population groups are better able to satisfy their reproductive desires with modern contraception. Where prevalence is low, nearly a third of the couples in the richest income group who wish to delay or avoid a birth use modern contraception. Among the poor, the proportion satisfying their desires(19) with modern methods does not reach this level until contraceptive acceptance is more widespread.

Differences between poor and rich populations’ access to family planning are staggering. In countries in sub-Saharan Africa, for example, women in the richest fifth of the population are five times more likely to have access to and use contraception than women in the poorest fifth.(20)

Figure 4: Average total demand in wealth groups

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Click here to enlarge image

Source: Data provided by K. Johnson, ORC MACRO, International, from Demographic and Health Surveys.
Figure 5: Percentage of family planning demand satisfied in different wealth groups at three levels of modern contraceptive prevalence

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Click here to enlarge image

Source: Data provided by K. Johnson, ORC MACRO, International, from Demographic and Health Surveys.
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