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"Unmet need" by Bill Ryerson Stampa E-mail
This paper is taken from a much longer paper I wrote in the 1990s, with updated data in the table on page 2.  It focuses on the fact that non-use of contraception by the 46 percent of the world’s married women who do not use modern contraceptives results primarily not from lack of access to supplies of family planning methods, but instead from cultural and informational barriers to use of existing supplies.

Even though use of family planning has grown from 10 percent of married women in 1960 to 54 percent today, the number of non-users exceeds the number of non-users in 1960 – because of population growth.  During this 47-year period, the reason for non-use has shifted from lack of access to attitudinal factors.  Clearly, “unmet need” is different from “unmet demand.”  The paper makes the point that communication strategies are now central to recruiting additional users of family planning.

William N. Ryerson

Unmet Need – Lack of Access or Lack of Cultural and Informational Support?
By William Ryerson
President, Population Media Center
July 18, 2007

Unmet need describes those women who want to delay their next pregnancy by at least two years but are not using a modern method of contraception.  In his 1991 analysis, John Bongaarts of the Population Council concluded that total "unmet need" was between 87 and 100 million women in the developing world outside of China.  Bongaarts concluded that many factors account for the gap, of which lack of access is only one. 

Kenya is an example of many African countries with regard to unmet need.  In Kenya, contraceptives were within reach of nearly 90 percent of the population by the late 1980s, according to a study by Charles Hammerslough in 1991.  The 2003 Demographic and Health Survey (DHS) from Kenya showed that 96% of married women and 98% of married men could name a modern method of contraception, while only 31.5% were using a method. 

Globally, the top reason for non-use of family planning is the desire for more children.  Since there are about 3 billion people of reproductive age, just over half of whom are using contraceptives, there are about 1.3 billion non-users, of whom only about 100 million can be described as having an unmet need.  The other 1.2 billion can be described as intentional non-users.  Even among those categorized as having an unmet need for family planning, the top four reasons for non-use are: 1) fear of the medical side effects of contraceptives; 2) male opposition; 3) religious opposition; and 4) fatalism.  The order of these reasons varies by country.  But these are all issues that are best responded to by information and motivational communications, and cannot be solved just through increased access to medical services – as important as access is.

Charles Westoff and Luis Hernando Ochoa determined in 1991 that about half the women categorized as having an "unmet need" have no intention of using contraceptives even if they are made freely available.  In other words, it is probably not theoretically possible to "meet" more than half of the remaining "unmet need" in the developing world without changing people’s minds about use of family planning methods.  In fact, the term "unmet need" is really a misnomer that has misled many people in leadership positions, who assume that "unmet need" means "unmet demand" and that such demand can be overcome by improving family planning services and contraceptive distribution.

Country by country, the Demographic and Health Surveys show a similar pattern.  Lack of access is cited infrequently by those who are categorized as having an unmet need for family planning.  The following chart illustrates that reasons having to do with information and cultural attitudes are predominant.

                                         Reasons Cited For Non-Use of Contraception
                                     By Non-Pregnant Women Who Are Sexually Active,
                                             Not Using Any Contraceptive Method and
                                     Who Would Be Unhappy If They Became Pregnant


                                   Percent Citing             Most Common
                                   Lack of Access             Reason
Country                       As a Reason (%)          

Botswana                    0.1                      Don't know (18.7)
Ghana                             0.6                      Fear of side effects (25.6)
Kenya                              0.2                      Religious prohibition (15.1)
Uganda                            0.4                      Side effects and health concerns (23.4)
Indonesia                         0.2                      Health concerns (26.3)
Nepal                               0.2                      Side effects and health concerns (16.8)
Dominican Republic          0.0                      Personal opposition (13.7)
Peru                                0.2                      Embarrassment (31.3)

A 1992 paper by Etienne van de Walle showed the importance of fatalism for many women and men.  Many people have simply not reached the realization that reproductive decisions are a matter of conscious choice.  Many who did not particularly want another pregnancy in the near future still reasoned that God had determined since the beginning of the universe how many children they would have and that it did not matter what they thought or whether they might use a contraceptive, because they could not overcome God's will.

Overcoming this situation takes more than access to contraceptive services.  It requires helping people understand that they are responsible for their own life experiences and that they have the power to effect changes in their life situation.

A 1992 publication of UNICEF carried the following statement:  "If all women were able to decide how many children to have and when to have them, the rate of population growth would fall about 30%."  If this statement is true, the stunning significance of it is that--if all women everywhere had full access to contraceptives and used them to have only the children they want – the rate of world population growth would drop only 30 percent.  A large share of the money and effort worldwide is going into solving 30 percent of the problem.

The above statement should not be interpreted as suggesting that the level of effort in providing contraceptive services be reduced.  High quality, low cost reproductive health care services are an essential element of fertility planning.  I happen to believe that both quality and quantity of contraceptive choices and services are in dire need of improvement throughout much of the developing world, particularly following the impact of the Bush Administration.  But access to family planning methods is not sufficient if men prevent their partners from using them, if women don't understand the relative safety of contraception compared with early and repeated childbearing throughout the reproductive years, or if women feel they cannot take control of their own lives.

REFERENCES

Bongaarts, John, 1991.  "The KAP-Gap and the unmet need for contraception."  Population and Development Review 17(2):  293-313.

Hammerslough, Charles R., 1991.  "Proximity to contraception services and fertility transition in rural Kenya."  Presented at the DHS World Conference, Washington, D.C.

Central Bureau of Statistics (CBS) [Kenya], Ministry of Health (MOH) [Kenya], and ORC Macro. 2004. Kenya Demographic and Health Survey 2003. Calverton, Maryland: CBS, MOH, and ORC Macro.

UNICEF, 1992.  The State of the World's Children.  New York.van de Walle, Etienne, 1992.  "Fertility transition, conscious choice and numeracy."  Demography 27 (4):  487-502.

Westoff, Charles F., and Ochoa, Luis Hernando, 1991.  "Unmet need and the demand for family planning."  Demographic and Health Surveys, Comparative Studies No. 5.  Institute for Resource Development/Macro Systems, Inc.  Columbia, Maryland.

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