The Unmet Need for Contraception in Developing Countries

Millions of women in developing countries who would prefer to postpone or avoid pregnancy do not use contraceptives. These women have an "unmet need" for contraception. By reducing obstacles to the use of contraception, family planning programs have been successful in addressing unmet need. Programs' principal methods for addressing this need have included emphasizing voluntary acceptance of contraception, educating couples about the range of methods and their possible health risks, and subsidizing the cost of contraceptives.

Unmet Need is a Global Issue

Unmet need is a disconnection between a woman's fertility preferences and what she does about them: She wants to avoid conceiving but fails to do what is needed to prevent pregnancy. The concept is usually applied to married women but also can apply to sexually active unmarried women and to those whose current method is inappropriate or inadequate. Survey research in developing countries estimates that more than 150 million married women of reproductive age have an unmet need for contraception. India has the highest number at about 31 million women (20 percent). In the majority of African and Middle Eastern countries studied and in a large number of countries in Asia, Latin America, and the Caribbean, at least 20 percent of married women of reproductive age had an unmet need for contraception. The countries with the highest percentage of women with unmet need are in Sub-Saharan Africa: Rwanda (37 percent), Malawi (36 percent), and Kenya (36 percent).

Family Planning Reduces Unmet Need by Addressing Obstacles to Contraceptive Use

Survey research conducted in 13 developing countries found that women cited a range of obstacles that prevented them from using contraceptives (see figure). Prominently cited are lack of knowledge about contraception, health concerns, high costs, limited supplies, and cultural or personal objections. Voluntary family planning programs—organized efforts to provide contraception and related reproductive health services—can address unmet need by addressing these obstacles.

NOTE: "Sources limited" is referred to as "lack of access/difficult to get" in the original study (Bongaarts and Bruce, 1995).

Lack of knowledge. The most widely mentioned obstacle was lack of knowledge about contraception, its use, or its availability, cited by one-quarter of those with unmet need. Effective family planning programs promote wider knowledge about the range of contraceptive methods and their proper uses. The proportion of women who cite lack of knowledge as a barrier to contraceptive use is substantially lower in countries where education programs are most active.

Health concerns. The second most widely mentioned obstacle is concern about the health effects of contraception, cited by one-fifth of the respondents. Family planning programs typically incorporate educational components to help women choose appropriate methods. These components also help couples better understand the relative risks involved. The health risks associated with contraception are low relative to the risks of a typical pregnancy and especially to the risks of an unintended pregnancy (because a number of such pregnancies are terminated by an unsafe induced abortion). In developing countries, the mortality risk of an unintended pregnancy carries 20 times the risk associated with use of a modern contraceptive method. Programs that offer a wider variety of contraceptive methods increase the chances that a couple can find a method appropriate for them. By helping couples find appropriate contraceptive methods, family planning reduces unintended pregnancies, which in turn decreases the number of abortions that result from such pregnancies.

Limited supplies and high costs. In some cases, contraceptives may simply be unavailable or too expensive for individuals. The cost can be substantial: The retail price of an annual supply of contraceptive pills exceeds $100 in some developing countries, as does the retail price of an annual supply of condoms. Contraceptive costs that reach 5 percent of average household income are common, and costs reach 20 percent of income in some Sub-Saharan countries. Family planning programs can make contraceptives more widely available and also reduce their cost for consumers by subsidizing prices.

Cultural/personal objections. Cultural and familial barriers to family planning may influence a woman's decision to use contraception. For example, a husband may disapprove because he wants more children or is concerned about health effects, bothered by the inconvenience, or distrustful of traditional methods. Such objections may reflect informational or access issues or health concerns. Except for a woman's personal opposition to contraception, the objections appear to be less prominent where programs are active. Family planning programs have demonstrated an ability to succeed in apparently unfavorable social and cultural environments. There have been success stories on all continents and in all cultural settings.

Challenges Remain

Family planning programs face continuing challenges in their efforts to address unmet need.

• Discontinued use of contraception. There are high rates of discontinuation of contraceptive use in some developing countries. Often, discontinuation results from insufficient counseling, lack of follow-up services, or lack of suitable alternative contraceptives. Women who receive counseling and are forewarned about the side effects of various methods use contraception longer than women who are not counseled. Discontinuation may also be based on religious or cultural grounds or objections from the male partner. This suggests that programs should emphasize appropriate counseling and involvement of male partners in decisionmaking to reduce discontinued contraception.
• Improvement of service delivery methods. Programs must continue to improve their methods of reaching client populations, especially younger adults. Young adults are a growing share of the world's population and have high levels of unmet need. Much of the need for contraception among this group is to space births. Given that delaying births can help reduce fertility faster and further, programs will need to refurbish their goals and promotional approaches consistent with the successful experiences of the past 30 years.
• Adequate funding. Historically, the United States has been the largest funder of international family planning programs. However, since 1995, the U.S. Congress has reduced bilateral international family planning assistance from $542 million annually to $385 million in 1997, and efforts to cut it further continue. It is unclear whether other donor nations are willing or able to make up the difference. The continued success of family planning in the next century will require stable funding sources at levels adequate to support needed services.