At the September 2005 United Nations (UN) World Summit in New York, the largest gathering of world leaders in history met to agree on next steps toward their ambitious plans to meet the needs of the world’s poorest people by 2015. These Millennium Development Goals (MDGs), the outcome of another historic conference in 2000, include eight broad agenda items relating to such topics as education, gender equality and health (see box).
Although reproductive health was not specifically included as an independent goal or a measurable target in the MDGs, for years experts have provided evidence that investing in reproductive health services is integral to meeting them all. Experts have feared, moreover, that by making no explicit mention of reproductive health as a goal, the MDGs had the potential to detract from targets on that front agreed upon at the 1994 International Conference on Population and Development (ICPD). One major outcome of the September 2005 summit, therefore, is a commitment to “achieving universal access to reproductive health by 2015” and to integrating this goal into the MDGs.
|THE MILLENNIUM DEVELOPMENT GOALS|
|1. Eradicate extreme poverty and hunger|
|2. Achieve universal primary education|
|3. Promote gender equality and empower women|
|4. Reduce child mortality|
|5. Improve maternal health|
|6. Combat HIV/AIDS, malaria and other diseases|
|7. Ensure environmental sustainability|
|8. Develop a global partnership for development|
A key step toward fulfilling this commitment could be taken in 2006, when UN panels convene to agree on new targets and measures to help assess progress in meeting the MDGs. A new target of universal access to reproductive health services, if adopted, would help mitigate the concerns of reproductive health experts by making an explicit link between the ICPD goals and the MDGs. Expert committees have also recommended the approval of a related measure, among others, known as “unmet need for contraception,” the proportion of women who are at risk of unintended pregnancy but not using contraceptives.
Such seemingly technical developments could go a long way toward shaping international assistance for family planning and meeting all of the MDGs. By pointing to women who have an unfulfilled desire to plan and space their childbearing, data on unmet need can demonstrate the work left to be done in assisting women and couples to prevent unintended pregnancies. In addition, such data could help gauge whether global financial support and the actions of world leaders are adequate for rectifying this problem.
The Concept of Unmet Need
Unmet need as a concept dates to the 1960s, when researchers first demonstrated a gap in the developing world between women’s fertility preferences and their use of contraception. This finding helped justify and structure investment by governments and nongovernmental organizations (NGOs) in family planning programs. Over the decades, researchers have honed the measurement of this phenomenon. For example, one major advance was the recognition that unmet need should encompass not only women who want no more children, but also those who want to space their births.
By the time of the ICPD in 1994, the concept of unmet need was also helping to mediate between the concerns of governments and experts focused on population growth and those of people primarily interested in women’s health and rights. Unmet need was helpful as a theory, because the “need” for contraception is largely a matter of whether and when a woman wants a child, or another one. By drawing on what women want, rather than what political leaders want, unmet need helped define family planning as an issue of individual rights. On a practical level, research by the early 1990s indicated that fulfilling unmet need would mean contraceptive use beyond the target set by almost every country that had set one. This research supports the argument made for years that helping women to achieve their own goals will also benefit society, without any need for coercive policies that had marred some countries’ population programs.
For the most part, the international community has now settled on a measure initially developed by Princeton University demographer Charles Westoff. This measure draws upon data collected through large-scale, nationally representative surveys of women, the Demographic and Health Surveys (DHS) and other related surveys, which are conducted periodically in countries across the developing world. The standardized measure has been included as part of the DHS reports produced for each country since the late 1980s. It is this measure that experts have recommended for monitoring progress in the context of the MDGs (see box). A second measure, unmet need for a modern contraceptive method, which excludes less-effective traditional methods such as periodic abstinence and withdrawal, has been recommended as a supplement.
The Extent of the Problem
According to a 2003 report from the Guttmacher Institute and the United Nations Population Fund (UNFPA)—Adding It Up: The Benefits of Investing in Sexual and Reproductive Health—there are 137 million women in the developing world with an unmet need for contraception, and another 64 million with an unmet need for a modern method. By identifying countries and populations with high levels of unmet need, governments and NGOs can target limited resources to where they may be most effective and welcome.
Unmet need for contraception is particularly high in Sub-Saharan Africa, where little progress has been made (see chart). Within every region, however, some countries and subregions stand out as clear targets for assistance. Although Nigeria, South Africa and many of their immediate neighbors have unmet need levels below 20%, Ethiopia, Senegal and several other countries on the east and west coasts of Africa have rates around 35%. Other regions, too, have their trouble spots: The rates for Cambodia (30%) and Haiti (40%), for example, are six times the lowest measured rates in their region—Vietnam (5%) and Colombia (6%), respectively.
|A JOB UNFINISHED||Unmet need for contraception has declined substantially across the developing world—except in Sub-Saharan Africa.|
|Source: Guttmacher Institute|
Policymakers can also target populations within countries where unmet need is most concentrated, according to characteristics such as age, income and education. For example, nearly nine in 10 women with unmet need in Morocco are aged 25 and older; in contrast, nearly half in India are younger than 25. Seven in 10 of those in need in Jordan live in urban areas, whereas eight in 10 in Bangladesh are rural residents.
The Impact of Family Planning
For decades, public-sector family planning programs have helped address the factors that prevent women and couples from meeting their contraceptive needs and desires. The programs make services affordable and accessible by providing free or low-cost contraceptives and educating women about what methods and services are available. In addition, the programs address women’s fears about contraceptives by providing accurate information to counter incorrect beliefs and by showing women how to manage the side-effects that are real. Furthermore, family planning programs improve couples’ communication about fertility goals and contraceptive practices and work to make practicing contraception more accepted in their communities.
All told, public-sector programs and private spending in the developing world are meeting the need of more than 500 million women for a modern contraceptive method, according to Adding It Up. These family planning services and supplies currently prevent 187 million unintended pregnancies each year, including 60 million unplanned births and 105 million abortions. This has measurable health benefits, including 2.7 million fewer infant deaths and 215,000 fewer pregnancy-related deaths. To put that in perspective, family planning services are preventing three-quarters of the abortions that would otherwise occur in the developing world each year (see chart). And beyond their medical impact, family planning programs also have far-reaching social, economic and psychological benefits for women, families and nations.
|IMPACT OF CONTRACEPTION||Use of modern contraceptive methods has greatly reduced abortion in the developing world, and it could reduce it even further.|
|Source: Guttmacher Institute|
In the process of helping women to achieve their childbearing goals, enormous amounts of government money are saved. For example, in a typical low-fertility Latin American country, every dollar spent on family planning saves $12 in health and education costs from averted pregnancies, abortions, births and complications. Although the savings are not quite so high in Sub-Saharan Africa because providing services also requires spending heavily to develop infrastructure, they are nonetheless real, and help drive critical investments for the future.
A Challenge Moving Forward
The $7.1 billion currently spent on family planning in developing countries—much of it contributed by donor countries and NGOs—pays for a year’s worth of modern contraceptive services to current users and maintains the family planning infrastructure. Continuing to meet this ongoing need is a critical first challenge.
The next step forward is to address the current extent of unmet need. If every woman in the developing world with an unmet need for a modern method began using one, an additional 52 million unintended pregnancies each year could be avoided. That would avert, for example, 22 million abortions—six in 10 of those that occur now in the developing world. Providing these services and supplies would cost an additional $3.9 billion per year, but the savings would ultimately dwarf that figure.
Beyond that, there are millions of women who experience contraceptive failure each year. Although no method is perfect, women and couples can be helped to practice contraception more effectively through better education and improved access to services. Moreover, as countries develop economically and in terms of education, people’s attitudes about family size tend to change. This, in turn, means that new women develop a need for contraception.
Sadly, the donor countries of the world have made scant recent progress in helping to provide contraceptive services to women who want and need them. Although funding for reproductive health activities more broadly has increased this decade, this overwhelmingly reflects new funding to combat the HIV/AIDS pandemic. In fact, according to UN figures, inflation-adjusted spending specifically for family planning has fallen considerably since the mid-1990s. The diverging trends in spending on family planning and HIV/AIDS run counter to the synergy between preventing unintended pregnancy and preventing HIV—let alone the synergies with the world’s other development goals.
U.S. funding for international family planning is particularly inadequate. Although it has long provided the largest share of global spending on family planning, the United States has consistently lagged far behind what many European countries contribute relative to their wealth. On top of this deficit, the Bush administration has proposed a cut to U.S. funding for international family planning for FY 2007 of at least 18% below its current level. And unlike any of its counterparts among donor countries, the United States routinely attaches ideological restrictions on its money that can impede the efforts of governments and NGOs to provide the services they judge to be most vital locally or to provide them through the most capable channels.
Reversing the recent U.S. and global trends around family planning funding and actually expanding aid to address the unmet need for contraceptive services should be regarded as a critical policy priority. Doing so would make a significant, measurable contribution to improving women’s health, and may have a similar impact on the world’s broader development goals, including the MDGs. Indeed, it seems doubtful that these goals can be met otherwise and without the United States playing a prominent leadership role.
Measuring Unmet Need for Contraception
The standard definition of unmet need, as used in the DHS, is complex. A woman is considered to have an unmet need if she:
• is married or in a consensual union and is of reproductive age (15–49);
• is capable of becoming pregnant (infecund women are identified based on such factors as their childbearing and contraceptive history and what they say about their ability to become pregnant);
• wants to have no more children or to postpone childbearing by at least two years; and,
• is using neither a traditional nor a modern method of contraception.
Women who are pregnant or who have recently given birth are considered to have an unmet need if their pregnancy or most recent birth was unintended.
A separate measure—unmet need for a modern contraceptive method, which excludes periodic abstinence and withdrawal—is often presented side-by-side with the standard statistic. In some ways, the two measures represent progressive steps toward the goal of ensuring that every pregnancy is a wanted one.
The current DHS standard measures of unmet need and unmet need for a modern method are undeniably imperfect. One problem is that they exclude unmarried women who are sexually active. In some parts of the world, governments have not allowed data to be collected on sexual practices outside of marriage; even when these questions are allowed, unmarried women may refuse to discuss or may underreport behavior that is not socially acceptable. Nevertheless, demographers do calculate unmet need among this group in countries where it is feasible, including Western countries and many in Sub-Saharan Africa. Researchers have also looked at unmet need measures for men and for couples, something that helps them study how relationship dynamics affect decisions about family size and contraceptive use. Despite some practical limitations, the DHS standard measure has gained broad acceptance and proven to be a reliable compromise between what is ideal in theory and what is practical for obtaining data that are comparable over time and across countries.