Unmet need for family planning

The number or percent of women 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, and (b) those with an unmet need for spacing.

Women with an unmet need for limiting are those who desire no additional children and who do not currently use a 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 contraceptive method.

The indicator is calculated as follows:

UL+ US = U

Where:
U   = the number or percent of women with unmet need for 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.

Note: The actual calculation of unmet need is fairly involved, as depicted in the United Nations Population Division's 2009 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. In the past, definitions of unmet need also used information from the contraceptive calendar and other questions that were not included in every survey – which led to unmet need being calculated inconsistently.  The definition of unmet need was recently revised in 2012, as explained in Revising Unmet Need for Family Planning. The revised definition of unmet need produces similar, although slightly higher, levels of unmet need compared with the original definition. In contrast to the original definition, the revised definition can be applied consistently to compare estimates across countries and to reliably measure trends over time.

Illustrative Computation
Estimate of unmet need for FP, Peru, 2000 (expressed as the percentage of women currently married or in union).

U = UL + US
= 6.7 + 3.5
= 10.2
Source of data: Peru Demographic and Health Survey, 2000


Responses to survey questions on:

  • Desire for additional children and, if so, the desired length of birth interval;
  • Current contraceptive use status;
  • 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; and
  • Use (or not) of a contraceptive method at the time of the current/last pregnancy.

Note: The use of the information in the final two items in the computation of the indicator is explained below.


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, but who do not use contraception. Such women have an "unmet demand" or "unmet need" for FP and are the logical primary audience of program efforts.

The indicator may also be interpreted as the number of additional clients who would be using contraception (over and above the number of current users) if all women at risk of pregnancy and desiring to either terminate or postpone childbearing were to adopt contraception.

The indicator follows from the breakdown of total demand for FP services into two components: "met demand" and "unmet demand" (or "unmet need"). Met demand consists of women with demand for FP 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.

Following the procedure proposed by Westoff and Ochoa (1991), women are considered to be at risk of pregnancy in the present indicator if they are:

  • Of reproductive age and currently married or in union;
  • Fecund;
  • Not using a contraceptive method; and
  • Not currently pregnant or amenorrheic.

However, the following categories of women are not considered to have an unmet need for FP, and thus, when computing the indicator, evaluators should exclude:

  • Currently pregnant or amenorrheic women who were using contraception at the time they became pregnant with the current/last birth (these women are viewed as not in need because prior need was met through contraceptive use, although they do appear to need a more effective method);
  • Currently pregnant or amenorrheic women whose pregnancy was reported as intentional; and
  • Fecund women who want their next child within the next two years.

A 2003 policy brief from Population Reference Bureau outlines the policy and program implications for determining unmet need.


Although unmet need for contraception has been a central indicator for monitoring the progress of FP programs for the past 25 years, its measurement contains numerous assumptions and imprecisions (Cleland, Harbison and Shah, 2014). One challenge pertains to reporting unmet need for married women, unmarried women, and all women of reproductive age. The MDG5 indicator is restricted to married or cohabiting women.  However, refining the population of interest refinement is particularly relevant for countries in which a significant share of childbearing occurs outside of recognized marriages/unions.

Some researchers have argued that the definition of unmet need should be broadened to include women using: (1) traditional contraceptive methods (on the grounds of high failure rates for such methods); (2) a theoretically effective method incorrectly or sporadically; and (3) a method that is unsafe or unsuitable for them (Foreit, 1992; Dixon-Mueller and Germain, 1992). The RHS modified the calculation of unmet need to include traditional contraceptive methods in countries where they are in widespread use (e.g., Eastern Europe, Turkey, Mauritius). The adoption of these alternative definitions would raise significantly the estimated numbers of women with unmet need for FP in many developing country settings.  Because of inconsistent collection of calendar data within and across countries over time, it raises problems with trend interpretation with measuring unmet need.

A related indicator, the satisfaction of demand for FP services, consists of the percentage of total demand for FP at any time that is being satisfied by current contraceptive use. Thus:

Satisfaction of demand for FP = contraceptive prevalence rate (CPR) / (CPR + unmet need)

Using an example from the Kenya 2008-2009 DHS, if unmet need for currently married women is 25.6 and CPR is 45.5, the percent of demand for FP satisfied is 64%:

(45.5 / (45.5 + 25.6)) x 100 = 64%

Another concern about this indicator is that it does not decrease linearly when FP programs improve and desired fertility decreases; initial improvements in FP programs can actually increase demand for contraception, which often causes demand to exceed the existing supply. As a result, unmet need will rise until supply shifts in response to 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).

The June 2014 special issue of Studies in Family Planning contains several articles pertaining to issues and challenges with this indicator and goes into detail about various considerations for calculating unmet need.  For instance:

  • For married or cohabitating women, no allowance in the measurement of unmet need is made for sexual abstinence.
  • Unmet need calculations for never-married or formerly married women may be downwardly biased.
  • Users of traditional methods are treated as nonusers based on the implicit assumption that they lack access to, or information concerning more effective alternatives.
  • 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.
  • The concept of unmet need is based on the discrepancy between future childbearing wishes and contraceptive use rather than from a direct expression of need by respondents (Cleland, Harbison and Shah, 2014).

policy, access, family planning, commodity, safe motherhood (SM)

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

Despite the nonlinear relationship between reducing unmet need for FP and increasing the CPR, the former is seen as an important strategy for achieving increased contraceptive use and decreasing total fertility. Thus, the relationship between contraceptive prevalence and poverty discussed above also applies to unmet need for FP.

Also, by decreasing unmet need, governments also will 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 developing countries found that in more than three-quarters of the countries, the poorest quintile experiences 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 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. Factors that 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?

 

2. Unmet need of women and men:

  • 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?

 

 3. Service-delivery issues:

  • 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 domestic 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?

Ashford, L. 2003. Policy Brief - Unmet Need for Family Planning: Recent Trends and Their Implications for Programs.  Population Reference Bureau and MEASURE DHS+. http://www.prb.org/pdf/UnmetNeedFamPlan-Eng.pdf

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.

Dixon-Mueller R and Germain A. 1992. "Stalking the Elusive 'Unmet Need' for Family Planning." Studies in Family Planning 23, 5:330-335.

Foreit K. 1992. "Unmet Demand for Contraception vs. Unmet Demand for Appropriate Contraception." Paper presented at the 120th Annual Meeting of the American Public Health Association.  Washington DC.

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

Kenya National Bureau of Statistics (KNBS) and ICF Macro. 2010. Kenya Demographic and Health Survey 2008-09. Calverton, MD: KNBS and ICF Macro.

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.

MEASURE DHS.  Peru: Standard DHS, 2000.

United Nations Population Division/DESA: Fertility and Family Planning Section.  World Contraceptive Use 2009: Unmet Need for Family Planning.  http://www.un.org/esa/population/publications/WCU2009/Metadata/UMN.html 

Westoff, CF and Ochoa LH. 1991.  Unmet Need and Demand for Family Planning. Demographic and Health Surveys Comparative Studies 5. Columbia, MD: Institute for Resource Development/Macro International Inc.

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

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