Family planning use and unmet need

JOHN CLELAND: In the next few minutes, I’m going to discuss trends in contraceptive use and an unmet need for family planning or contraception. Both are measured in surveys. Contraceptive use is ascertained by asking women if they’re currently using any method of contraception and if so, which one? Methods are often divided into two types– modern, more effective methods, and so-called traditional or less effective methods, the most common of which is withdrawal, or to give it its proper name, coitus interruptus. Unmet need is derived from questions on desire for more children and, if more are desired, how long the woman wants to wait till the next birth.

So a woman with unmet need is one who’s using no method, or alternatively, no modern method of contraception, and who wants no more children or wants to delay the next child for two years or more. Both contraceptive use and unmet need are usually based on all married women in the reproductive age span of 15 to 49 years, but they can also be based on married women plus sexually active unmarried women. This figure shows trends between 1970 and 2010 in the percent of married women who reported use of any method and the percent of married women with an unmet need. Data is shown for major world regions.

As you can see, in North America and in Europe, contraceptive use was already high, and unmet need already low in 1970, and not much has changed since then. The contraceptive revolution obviously started early in these two regions. In developing regions, on the other hand, as you can see in this slide, much has changed since 1970. In that year, contraceptive use, the green line, was low– about 30% in Asia and Latin America, less than 20% in North Africa, and only 5% in Sub-Saharan Africa. By 2010, use had climbed to around 70% in Asia and Latin America and about 50% in North Africa.

Government promotion of contraception can take much of the credit for these huge changes in behaviour, and rising educational levels and incomes also had a major influence. But the single biggest cause is the huge prior decline in child death rates. When few children die, it’s inevitable that couples will be more ready to practise contraception. Sub-Saharan Africa– that’s the bottom left plot on the slide– has seen the smallest change. Even in 2010, only about 25% of married women were using any method of contraception. This situation reflects low levels of education and incomes, together with historically high levels of child death. In addition, many governments in Africa, until recently, have been reluctant to promote contraception.

Turning now to unmet need, that’s the blue line, Figure 1 also shows that unmet need for family planning has fallen from around 30% in 1970 to around 10% 40 years later. Sub-Saharan Africa is again the exception. Here, unmet need has remained pretty much unchanged, at close to 30%, over the last 40 years. In other words, almost one in three women in Africa do not want to get pregnant, but are using no method of contraception. This is the big message I want to get across– that 222 million women in the world– in developing countries, rather– have an unmet need for modern contraception. That’s a huge number. Let’s look more closely at it in this slide.

This figure provides a closer look at recent levels of contraceptive use and unmet need for subregions of the developing world. Unlike the previous figure, sexually active single women are now included and uses of less effective traditional methods are classified as having an unmet need. The top bar shows the situation for the developing world as a whole. 57% of all married and sexually active women are using a modern method. That’s the dark bit of the bar. And 18%, the light bit of the bar, have an unmet need. The remainder not shown in the bar either want another child within two years or are unable to bear children.

Now, 18% unmet need may not sound a large fraction, but it represents those 222 million women. Why do so many women not use an effective method when they say they don’t want to get pregnant? Research shows that many factors are responsible. In countries where contraceptive use is low, as in much of Sub-Saharan Africa, ignorance of methods and lack of access are important. In high use countries, a common reason is a perceived low risk of getting pregnant. But worldwide, fear of side effects or fear of damage to health from using a modern method is the most frequently cited reason.

Going back to the figure, the very low levels of modern method use and high levels of unmet need in Western and in middle Africa are striking. The length of the bars for these two subregions also show that over 50% of women want another child within two years, and thus do not have an unmet need. At the other extreme is Eastern Asia, with exceptionally high use of modern methods. This reflects the situation in China where childbearing is limited by state decree and IUDs and sterilisation have been strongly promoted. The mandate of family planning promotion and programmes is to reduce unmet need and thereby reduce the number of unintended pregnancies.

As the figure indicates, unmet need for family planning remains common in all subregions of the developing world apart from Eastern Asia. Despite the remarkable progress of the last 40 years, much remains to be done.