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Reproductive Health and Family Planning
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
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
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
Click here to enlarge image
Source: Data provided by K. Johnson, ORC MACRO, International, from Demographic and Health Surveys.
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