A primary objective of family planning programs has been to reduce unintended births by address- ing “the unmet need for contraception.” This unmet need is conventionally estimated from representative population- based surveys of currently married women as the sum of the number of currently pregnant women who report that their pregnancy is unintended and the number of currently nonpregnant women who are not using contraception and would not like to have any more children or, at least, none in the next two years (Bankole & Westoff, 1995). On the basis of this defi- nition, the unmet need for contraception (TABLE 5-8)
Country Unmet Need Current Use of
Contraception Demand for
Family Planning Percentage of Total Demand Satisfied Sub-Saharan Africa
Benin, 2011–2012 32.6 12.9 45.5 28.4
Cameroon, 2011 23.5 23.4 46.9 49.9
Chad, 2014–2015 22.9 5.7 28.6 19.8
Congo, 2011–2012 18.4 44.7 63.1 70.9
Democratic Republic of the
Congo, 2013–2014 27.7 20.4 48.1 42.5
Ethiopia, 2011 26.3 28.6 54.9 52.1
Ghana, 2014 29.9 26.7 56.6 47.2
Guinea, 2012 23.7 5.6 29.3 19.1
Lesotho, 2014 18.4 60.2 78.6 76.5
Liberia, 2013 31.1 20.2 51.3 39.4
Malawi, 2010 26.2 46.1 72.3 63.8
Mali, 2012–2013 26.0 10.3 36.3 28.5
Namibia, 2013 17.5 56.1 73.6 76.2
TABLE 5-8 Unmet Need for Contraception and Demand for Family Planning for Married Women in 37 Countries, Based on DHS Survey in 2010–2015
(continues)
Country Unmet Need Current Use of
Contraception Demand for
Family Planning Percentage of Total Demand Satisfied Sub-Saharan Africa
Niger, 2012 16.0 13.9 29.9 46.5
Nigeria, 2013 16.1 15.1 31.2 48.5
Rwanda, 2014–2015 18.9 53.2 72.2 73.8
Senegal, 2014 25.6 22.2 47.7 46.4
Swaziland, 2006–2007 24.7 50.6 75.4 67.2
Tanzania, 2010 22.3 34.4 56.7 60.6
Uganda, 2011 34.3 30.0 64.3 46.7
Zambia, 2013–2014 21.1 49.0 70.2 69.9
Zimbabwe, 2010–2011 14.6 58.5 73.1 80.1
North Africa/West Asia/ Europe
Armenia, 2010 13.5 54.9 68.4 80.3
Egypt, 2014 12.6 58.5 71.1 82.3
Jordan, 2010 11.7 61.2 72.9 83.9
Asia
Bangladesh, 2014 12.0 62.4 74.4 83.9
Cambodia, 2014 12.5 56.3 68.8 81.9
Indonesia, 2012 11.4 61.9 73.2 84.5
Pakistan, 2012–2013 20.1 35.4 55.5 63.8
Latin America and Caribbean
Colombia, 2010 8.0 79.1 87.1 90.8
Dominican Republic, 2013 10.8 71.9 82.7 86.9
Haiti, 2012 35.3 34.5 69.8 49.4
Honduras, 2011–2012 10.7 73.2 83.9 87.3
Data from Macro International Inc., 2010–2015, MEASURE DHS STAT compiler. Accessed on November 10, 2016 from http://www.measuredhs.com
TABLE 5-8 Unmet Need for Contraception and Demand for Family Planning for Married Women
in 37 Countries, Based on DHS Survey in 2010–2015
(continued)is estimated to be 20% or less for married women in countries with high contraceptive prevalence rates (e.g., 55% or higher) and ranges up to 30% (Uganda) of women in countries with lower contraceptive prev- alence rates.
The definition of “unmet need for contraception”
has been criticized as an underestimate of actual need because it excludes both currently married women who are not pregnant and who are using inappropri- ate (because of health consequences or side effects) methods of contraception and sexually active women who are not currently married and who do not wish to become pregnant, at least in the next two years ( Bongaarts, 1991; Dixon-Mueller & Germain, 1992;
Pritchett, 1994a, 1994b). An additional criticism revolves around the issue of ineffective contraception.
Large numbers of women currently use traditional methods, which have much higher failure rates than available modern contraceptives. Current estimates of unmet need do not include women who are using tra- ditional (i.e., ineffective) contraceptive methods.
More recent estimates (2007) consider unmar- ried as well as married women. They show that for all LMICs, approximately 112.4 million women have an unmet need for contraception (108 million married and 4.2 million unmarried). These numbers translate into 14% of married women versus 7.7% of unmar- ried women having an unmet need for contracep- tion. Women age 15 to 24 have significantly higher unmet need than 25- to 49-year-old women (Sedgh, Hussain, Bankole, & Singh, 2007). More than half of the total unmet need for contraception is attributed to the need to space births, and the other half to the need to limit births (Ross & Winfrey, 2002). The total number of women whose needs are unmet results from the combination of upward pressure due to population growth and downward pressure due to the success of family planning programs (Ross &
Winfrey, 2002).
Family planning programs have played an important role in reducing the unmet need for con- traception by making contraceptive options both physically accessible and financially affordable. Since the late 1950s, when the first national family plan- ning programs in LMICs were established, there has been a significant increase in the prevalence of con- traceptive use. This increase has played an important role in the significant reduction in fertility that has taken place especially over the last three decades in these regions, where the average number of births per
1 The onset of fertility decline is usually dated from an initial decline of at least 0.7 point in total fertility over a five-year period, following the practice employed by Bulatao and Elwan (1985).
couple declined from more than 6 to fewer than 3 in the latter half of the twentieth century.
Program success in improving contracep- tive prevalence rates has, however, been somewhat uneven. It has depended on a number of factors, including a receptive social and family environment that accepts fertility control as legitimate behavior, a favorable political and bureaucratic climate, a man- agement structure that pays close attention to both quality and quantity of services, and reliable sources of funding. Furthermore, those programs that have succeeded have invested considerable resources in evaluation, research, and monitoring of their services, and have had the flexibility to adapt to local condi- tions ( Bongaarts, 1997; Bongaarts & Watkins, 1996;
Bulatao, 1993, 1998; Freedman, 1987).
A long-standing debate has focused on the rel- ative merits of “demand-side” versus “supply-side”
interventions to reduce the unmet need for contra- ception (Bongaarts, 1997; Pritchett, 1994a, 1994b).
Demand-side proponents argue that improvements in women’s socioeconomic status are an essential and necessary prerequisite to the success of family plan- ning programs. Thus, educated women with higher status, compared to their less-educated and lower- status peers, are more likely to know about contra- ception and to seek it out to actualize their latent fertility desires. Supply-side proponents, in contrast, posit that family planning programs, when properly managed, can increase access to and availability of contraception, even in the absence of changes in the socioeconomic status of women. Thus, they can lead to increased contraceptive prevalence rates and initia- tion of fertility decline.
The experience of many countries shows that the onset of fertility decline1 is not dependent on any particular threshold in socioeconomic factors such as levels of urbanization, female education, or infant mortality. In fact, fertility decline appears to have started in a wide range of LMICs at quite varied lev- els of socioeconomic status. Bangladesh is frequently cited as the best example of improved contraceptive prevalence rates and dramatic fertility decline in the absence of socioeconomic improvements but in the presence of a well-run, sharply focused family plan- ning program (Cleland, Phillips, Amin, & Kamal, 1994), although the absence of socioeconomic change has recently come under question (Caldwell, Barkat, Caldwell, Pieris, & Caldwell, 1999; Menken, Khan, &
Williams, 1999). While there appears to be no magic
threshold of socioeconomic development for initia- tion of fertility decline, the decline occurs more rap- idly in countries with greater levels of socioeconomic development (Bongaarts & Watkins, 1996).
The demand-side versus supply-side debate is basi- cally a false dichotomy. Neither development nor fam- ily planning programs are a necessary prerequisite, nor is either sufficient to induce fertility decline on its own (Ross & Mauldin, 1996). Rather, these factors work in a complementary fashion, with the time scales of their respective impacts being very different. On the one hand, investments in improving women’s status and educational attainment certainly have an important impact in reducing unmet need, but it is a long-term impact. On the other hand, family planning programs can increase access to contraception in the short run, thereby enhancing knowledge about its use and avail- ability and addressing many of the negative myths about particular methods of contraception. Appro- priately crafted and focused media campaigns, when implemented as part of family planning programs, can also help legitimize contraception as an acceptable and desirable form of behavior. Moreover, it is import- ant to note that access to the means to limit fertility in and of itself helps improve the status of women.
Family planning programs work synergistically with improvements in socioeconomic status and are most effective when they are directed at an informed, edu- cated, empowered client base (Freedman, 1987).
In summary, Bongaarts (1997) estimates that approximately 40% of the fertility decline in the last three decades of the twentieth century in LMICs (from a TFR of 6 to 3 births per woman) can be attributed to family planning programs, and approximately 60%
to changes in socioeconomic status, particularly for women.