Intended Contraceptive Use Among Women Without an Unmet Need
Many women with an unmet need for contraception report that they do not intend to use a method, while others, not classified as having an unmet need, say they do intend to use. Contraceptive outreach programs have not sought out the latter group of women, who constitute a large reservoir of potential users. Demographic and Health Survey data from 25 countries show that in 15 countries, those without an unmet need who intend to practice contraception outnumber women with an unmet need who do not intend to do so; in Colombia and Zimbabwe, for example, they are four times as numerous. Among women who intend to use a method, those who have an unmet need for contraception to space the next birth are similar to those without an apparent unmet need in age and family size, and they have a similar record of past contraceptive use; however, those without an unmet need are more likely to be pregnant (34% vs. 28%) and to say they wish to defer use for at least one year (34% vs. 23%). Women with no unmet need who plan to use a method are also generally similar to current users in family size, though they are a little younger and are considerably more likely to have had a recent birth.
(International Family Planning Perspectives, 23:148-154, 1997)
Fecund married women of reproductive age who are not practicing contraception and say they want a child within the next two years typically are not classified as having an unmet need for contraception. However, many such women say they intend to use a method at some time. An analysis of the 1993-1994 Bangladesh Demographic and Health Survey (DHS), by Abul Barkat, showed that they can even outnumber women classified as having an unmet need who did not intend to use a method.1 This result is confirmed, to a substantial extent, in most of the DHS surveys discussed below.
Thus, a large market for family planning services may exist among women who have been overlooked by programs trying to address unmet need. Who are these women, and how do their characteristics compare with those of women who are considered to have an unmet need and plan to use a contraceptive method? If the two groups are basically similar, programs can use a unified approach to offer information and services to both.
In this article, we use data from 25 recent DHS surveys to compare the sizes and characteristics of the two groups, gauge the intensity of interest in using contraceptives among women not considered to have an unmet need and suggest implications for programs.
FRAMING THE ISSUES
Years ago, DHS and other surveys established that a great deal of unmet need exists in most countries.2 Unmet need can be defined in many ways, however, and the more generous the definition, the greater the numbers—as when unmarried persons, dissatisfied users or couples relying upon traditional methods are included.3
The definition used here is confined to fecund married women of reproductive age who are not using a contraceptive method even though they wish to avoid pregnancy. They have an unmet need for limiting if they never want another child, and for spacing if they wish to postpone the next birth for 24 months or more. If they are pregnant or amenorrheic, and the pregnancy had been unwanted or mistimed, they are considered to have had an unmet need at the time of conception, unless they had been using a method when they conceived and experienced a method failure.
Some commentators have noted that unmet need is a statistical construct, in the sense that surveys do not directly ask respondents if they have a felt need for a contraceptive method or for assistance in obtaining one. Nevertheless, surveys ask women about their intentions to use a method, and the answers to those questions are central to our analysis.
The understanding of unmet need for contraception has passed through a series of stages, each one an outgrowth of the ones before. One study has shown that by the usual definition, the number of couples with an unmet need is so large that if these couples became users, contraceptive prevalence would rise to exceed the targets of most countries.4 That finding considerably strengthened the case against local recruitment quotas for workers and may have contributed to India's decision in April 1996 to discontinue its target system.
However, other research has found that substantial proportions of women defined as having an unmet need say they do not intend to use a method,5 and these women cite a great variety of reasons in answer to superficial survey questions.6 Yet another analysis has demonstrated that if even a modest proportion of those with an unmet need initiated contraceptive use, the demographic effect would be appreciable.7
It also has become eminently clear that for most women with an unmet need, questions of birth planning are salient and timely. Westoff and Bankole have shown that between one-third and one-half of women with an unmet need are pregnant or amenorrheic, and notable proportions are within a few years of their most recent birth.8 Women with an unmet need are predominantly in the active childbearing years; they are relatively young and have small or medium-sized families. Roughly half have never used a contraceptive method, and many encounter another, unwanted pregnancy before they adopt a method.9
The recognition that many women who are not classified as having an unmet need still plan to use a method forces attention to yet another refinement of these issues. Women without an unmet need are a complex group: Some are already using a method, while others are infecund and have no reason to practice contraception. Some are young and want another child; of these, some intend to use a method and others do not.
The women we are concerned with here have said both that they want a child within the next 24 months and that they intend to use a method. For consistency with the DHS terminology, we refer to them as not having an unmet need, even though their interest in contraception makes this a contradiction in terms. The question is how to reconcile their desire for a birth within 24 months and their intention to use a contraceptive, most of them within the next year.
INTENTION AND UNMET NEED STATUS
A key question in estimating the market for family planning services is whether the women classified as having an unmet need who do not intend to use a method are outnumbered by those not considered to have an unmet need who do intend to use. As an example, Figure 1 shows the distribution of respondents in the Bangladesh DHS by contraceptive use, unmet need status and contraceptive intention.
Of the 2,060 women in the sample with an unmet need, 65% intend to use a method; similarly, 68% of the 2,918 women without need intend to use. Moreover, nearly equal numbers in the two groups intend to use within the next 12 months (1,018 and 1,058, respectively). Overall, women with no unmet need who intend to use a method outnumber those with an unmet need who do not intend to use by a ratio of 2.7 to one.
Figure 2 shows this ratio for 25 countries and also shows whether women planned to use a method within the next year or later. (All countries are treated individually rather than by region; we detected only minor regional differences in the patterns, partly because some regions have few applicable DHS surveys.) The total ratios are high indeed, exceeding 4.0 for Colombia and Zimbabwe, and ranging between 1.7 and 1.9 for six others. Altogether, 15 countries have ratios exceeding 1.0, meaning that women who were thought to be in need of contraception but do not plan to use a method are outnumbered by those not considered to be in need who nevertheless intend to use one.
If we look only at those women who intend to use a method soon, the ratios are still impressive. Ratios for three countries exceed 1.5 (meaning that there are at least 50% more women who intend to use soon than there are those who do not intend ever to use), and seven others are between 1.0 and 1.5. In another eight countries, more than half of women from the unmet need group who do not intend to use contraceptives are replaced by women with no recognized unmet need who intend to use soon.
The ratios for the residual group—those intending to use later—are smaller. Sixteen countries have a ratio below 0.5, of which 12 are below 0.4. Thus, most women without need who plan to use at all intend to do so soon. In sum, it appears that a large reservoir of interest in contraceptive use exists in addition to the population with an unmet need.
WOMEN WHO INTEND TO USE
If the two groups who intend to use a method—i.e., those with and without an unmet need—are similar enough, programs can efficiently seek out both, using similar strategies. We examined six characteristics of women who intend to use a method: two on the stage of family building (age and family size), two on the phase within the birth interval (time since last birth and proportion pregnant) and two on contraceptive use (never used and plan to use only after one year).
A three-way comparison was required, since women with an unmet need must be separated into those wishing to delay the next birth and those wishing to limit further childbearing. In general, we found that women who desire no more children are different from either those who would like to space future births or those without unmet need, whereas the second and third groups are similar in numerous characteristics (Table 1); the last two, therefore, are discussed first.
Overall, about 40% of both spacers with an unmet need and women without an unmet need are between 15 and 24 years of age; at the regional level, the same is true in Africa and Asia. Spacers are younger than women without an unmet need in Latin America and the Near East. (Given that the DHS covered only a small number of countries in some regions, and not all large countries are included, some results may not be generalizable to the regional level.)
With respect to family size, the two groups are again similar; about seven in 10 women in each have three or fewer children. In Africa, this proportion is smaller among spacers with an unmet need than among women without an unmet need, but no difference appears in the other regional means.
In every region, a birth within the past 15 months is less common, and a current pregnancy is more common, among women without need than among those in need for spacing. This is not surprising, since by the DHS definition, pregnant women who say they wanted the pregnancy are classified as not having an unmet need. On the other hand, some women who wanted their current pregnancy indicated that they did not want another one (either soon or ever), and intended to seek a contraceptive method.
The two groups are nearly identical in the proportion saying they have never used a method—55-56% for the 25 countries overall and similar proportions in all regions. However, they differ with regard to when they intend to adopt a method: Roughly one-third of those with no unmet need say they will defer use beyond one year, compared with about one-quarter of those with an unmet need for spacing. The pattern is the same in each region, although the proportions are somewhat lower in Latin America.
Pregnant women, with some months to go before birth and with amenorrhea to follow, may tend to say they will use a method "later" rather than "within the next year." Others, in saying "later," may be thinking of the period after their next birth rather than before. Also, their motivation may be weaker than that of women with an unmet need, who definitely wish to defer pregnancy for a longer period.
Women in the third group, who wish to limit births, are older and have larger families than those in the other two groups, and smaller proportions have had a recent birth or are pregnant. They report somewhat more past contraceptive use, but the differences are not great; in fact, the three groups are more alike on this feature than on any of the others.
These findings suggest that program assistance is clearly relevant for many or most women who intend to use a method—both those with an unmet need for spacing or limiting and those categorized as having no unmet need. However, judging by the responses regarding timing of use, women without an unmet need are generally less motivated to use—in some cases because they are pregnant and will be protected for some time by pregnancy and postpartum amenorrhea, and in others because they wish to become pregnant and have another birth before beginning use. Alternatively, their intention may be firm but simply placed further into the future. Therefore, we next explore the question of the intensity of attitudes toward future use among women without an unmet need.
INTENSITY OF INTEREST
Among women without an unmet need who intend to use a method, 66% plan to begin use within a year. How are they different from their counterparts who intend to use later?
Averages across the 25 countries (Table 2) indicate that those who plan to use soon are older than those who intend to use later (26.7 vs. 25.9 years), have larger families (2.9 births vs. 2.1) and have given birth more recently (23 months ago compared with 32). Further, a greater proportion of those who plan to use soon are pregnant (38% vs. 26%), and a substantially higher proportion are amenorrheic (47% vs. 26%). They also have somewhat more experience with contraceptive use,* although the difference is not great (48% vs. 41%). The 25 countries are remarkably consistent in the direction of these comparisons; few break the pattern for any of these measures.
Thus, women who plan to use soon, being of higher parity and closer to recent pregnancies, are clearly under greater pressure to use a method. Given their stronger motivation to use, they are more likely to actually begin use, even though they also say they would like another child sometime in the next two years. As a measure of the intensity of intent, the expressed timing of use is the best DHS indicator available at present, but consideration should be given to the development of more detailed questions.
Another way to gauge the seriousness of intent among women without an unmet need who intend to use is to compare them with current users. If these two groups are generally similar, the likelihood is greater that those who intend to use will actually do so. The best comparison is with users who are spacing, since they, like the women without an unmet need, have said they want another child.
The intending women without unmet need, in most countries, have about the same family size as women who are using a method to space the next birth: Roughly three-quarters of each group have three or fewer children (Table 3). However, intenders are more likely to be aged 15-24 (43% vs. 37%) and to have given birth within the past 15 months (48% vs. 36%). It is not surprising that women who recently gave birth have not yet begun (or resumed) use, since many believe themselves to be protected by lactation, and some have not yet managed to obtain a contraceptive method. Nevertheless, many have used before: On average, 45% of women with no apparent unmet need have used a method in the past (Table 1), and 31% have used a modern method (not shown).
Of course, some women who intend to use a method conceive accidentally before they begin to do so, and some fail to adopt a method because of their own ambivalence or family opposition. Nevertheless, with regard to past contraceptive practice, family size and recency of the last birth, women with no unmet need who intend to use a method are not so different from current users, and their survey responses about intentions to use deserve to be taken seriously.
UNMET NEED AND PREVALENCE OF USE
An unresolved question is the relationship, over time, between unmet need and the prevalence of contraceptive use. For program planning, this is of particular interest. Although some information exists at the population level,10 little has been done on how individuals move into and out of the group with an unmet need and the group of users (except in Morocco11 and in parts of Gujarat State, India 12). A similar question exists with regard to those who intend to use: If they implement their intention, the group of users will grow, but meanwhile some women will cease use and leave the group, so the net gain will be less.
The number of users is reduced when women cease to be of reproductive age, when marriages dissolve, when women die and when they discontinue method use. Probably the last of these reasons is the primary one: Women who were using a method to space decide to have the next birth or terminate their use because of side effects or for other reasons.
Using DHS information, we estimated for some countries the proportion of women using methods for spacing who terminate use each year. While the behavior of women who are spacing could be traced during the last completed interval of use, we can develop an approximate but more recent estimate from their current interval of use. For example, in a steady state, where entries and exits for the group of users has become stable, if a group of women currently using a method to space births have been using their method for 18 months, their average duration of use would be double that, or 36 months. That is, on average, they are interviewed at the midpoint in their segment of use. Then the estimated annual termination rate is the reciprocal of the estimated duration of use, in years. Thus, for our hypothetical group whose estimated duration of use is 36 months, or three years, on average, a third of these users would terminate each year and would be replaced by entries from among intenders.
Using this indirect methodology, we calculate that for 11 DHS countries with recoded calendar information, 19-37% of women practicing contraception for spacing purposes would be expected to terminate use annually (Table 4). Relatively favorable continuation rates can occur where the body of users is large in relation to annual new adoptions, since established users are likely to have low current termination rates.
For service programs, all women who intend to use a method are of interest, and many of those not classified as having an unmet need for contraception may be important candidates for method adoption for spacing purposes. Between two-thirds and three-fourths of these women are either pregnant or amenorrheic (well above the one-third to one-half cited for the total group with an unmet need), and they understandably do not want another pregnancy soon. Also, most say they intend to use a method within the next year, rather than later. Therefore, much of their interest appears to be in the temporary use of a method during the interval before they conceive again.*
The minority who wish to use "later" (i.e., sometime after one year) probably include some who are thinking of the period after their next birth. In fact, they may be much closer to another pregnancy than those wishing to use a method soon. In terms of the flow of women into and out of the various classifications, those planning to use contraceptives later are of interest for program services primarily for information and counseling.
Clearly, women with no unmet need who intend to use a method have much in common with women with an unmet need who wish to space—at least in terms of the characteristics examined in this article. Our results imply that the 24-month cutoff traditionally used to identify women who wish to space births is problematic. Women who are close to either side of the cutoff are not substantially different from each other, and many who wish to use within 23 months or less are genuinely interested in the short-term use of contraceptives. They are as much "in need" as women traditionally classified as having an unmet need for spacing.
This suggests that attention might be given to a modification of the DHS questionnaire to inquire into the motivational levels of women across a wider range. Apparently, the count of women interested in spacing would be appreciably larger than previously estimated.
Women who want to limit further childbearing are clearly different from others, but the distributions according to various characteristics overlap a good deal. Thus, while programs can use generally similar approaches for them as for the other groups in conducting public education and in locating interested clients, staff cannot depend quite as much on the signals of a recent birth, a current pregnancy, a small family, younger age and no past use. (The system of worker records can often be modified to reflect the reproductive preferences of each couple. For example, in Bangladesh the fieldworker has three indicators of unmet need for each woman in her assigned area: age, number of children and age of the youngest child. It would be feasible to add two others: desire for another child, and if so, when.)
Nevertheless, those interested in limiting future births who are successfully located may prove to be highly motivated to use a method, and many of them will wish to use it soon. Method choice is important: Many of these women have used a method in the past but are not doing so now; some discontinued use because of side effects, so new alternatives must be available.
The question has been raised as to why program resources are needed to assist couples who already say they intend to use. The answers are several: For some, no help is needed. But women in poor rural populations do not necessarily have a clear, well-articulated life plan and the means to fulfill it. Many couples are young and on unfamiliar ground, with each other and with outside services. For them, adoption of a method is often preempted by an unwanted pregnancy. And saying in an interview that they intend to use a contraceptive is not the same as taking effective action. Consequently, family planning programs need to continue outreach to individuals who say they intend to use—even if traditional measures seem to say they have no unmet need for services.
*In the six Latin American and three Near Eastern countries, most use has been of modern methods. In Africa, however, modern methods predominate only in three countries (Ghana, Namibia and Zimbabwe). *A woman who wishes to have consecutive births within 24 months would have to conceive no later than 15 months after the first birth. Probably many respondents think only in general terms, not wanting another pregnancy right away, but not fully realizing that the period for contraceptive use is rather brief if they are to conceive within 15 months of their last birth. Also, many may fail to take into account the likelihood of not conceiving exactly when they wish, with a consequent delay past 24 months. John Ross is senior fellow, and Laura Heaton is senior research associate, both at The Futures Group International, Glastonbury, CT, USA. This research was initiated under funding from the Rockefeller Foundation, for which the authors express their appreciation.
2. C.F. Westoff and L.H. Ochoa, "Unmet Need and the Demand for Family Planning," Demographic and Health Surveys Comparative Studies, No. 5, Macro International/Institute for Resource Development, Columbia, Md., USA, 1991; and C.F. Westoff and A. Bankole, "Unmet Need: 1990-1994," Demographic and Health Surveys Comparative Studies, No. 16, Macro International/Institute for Resource Development, Columbia, Md., USA, 1995.