A global analysis of Demographic and Health Survey (DHS) data suggests that in Africa, one in four married women of reproductive age have an unmet need for contraception.1 On average, in the 31 African countries included in the study, 24% of married women had an unmet need; mean levels were lower in Asia (15%) and Latin America and the Caribbean (13%), though those regions were not as well represented by DHS data. The most frequently cited reasons for not using contraceptives were lack of regular sexual activity, cited by a third of women in Latin American and the Caribbean and Asia; concern about side effects and health risks, cited by one in four women in all three regions; and opposition to contraception, mentioned by a quarter of women in Asia and Africa. Lack of access was not a commonly cited reason for nonuse in Latin America or Asia, but was often mentioned in some African countries.

Recent estimates suggest that more than 220 million women in the developing world have an unmet need for modern contraceptive methods, and that meeting all of this need would prevent at least 54 million pregnancies annually. To examine levels of unmet need and reasons for nonuse of contraceptives, Sedgh and Hussain examined data from 51 DHS surveys conducted in developing countries between 2006 and 2013. Analyses were limited to married women of reproductive age (15–49), as many of the surveys did not include unmarried women or did not ask them about sexual activity. Women were considered to have an unmet need if they were fecund, did not want a child in the next two years (or ever) and were not using a modern or traditional method of contraception; those who were pregnant or experiencing postpartum amenorrhea were considered to have an unmet need if their current or recent pregnancy was unintended.

Thirty-one of the surveys were conducted in Africa, and together represented 74% of the continent’s married women aged 15–49. Thirteen were conducted in Asia, representing 75% of women aged 15–49 in South Central, South Eastern and Western Asia; however, no DHS data were available for Eastern Asia. Finally, seven surveys were done in Latin American and the Caribbean; because these surveys represented only 19% of the region’s reproductive-age women, the authors caution that the resulting aggregate data should not be considered representative.

Overall, the proportion of married reproductive-aged women who had an unmet need for contraception was 24% in Africa, 15% in Asia and 13% in Latin America and the Caribbean. Subregional estimates for Eastern Africa (26%), Middle Africa (26%), Western Africa (24%), South Central Asia (15%) and Southeastern Asia (14%) were similar to the corresponding regional estimates; the analysts did not calculate subregional estimates for other areas because the sample represented less than half of each subregion’s population. Among individual countries, levels of unmet need were lowest in Colombia (9%) and Peru (10%), and highest in Sao Tome and Principe (38%), Ghana (36%) and Liberia (36%); it exceeded 25% in nearly two-thirds of African countries.

On average, women cited 1.2 reasons for not using contraceptives, though the researchers suspect that many women contended with additional barriers that they did not report. The prevalence of these reasons often varied widely by region. Infrequent or no sexual activity was cited as a reason for nonuse by a third of women in Latin American and the Caribbean (34%) and Asia (31%), but by only one in five women in Africa (19%). Concern about side effects and health risks was the most commonly mentioned reason in Africa (28%), and among the most cited reasons in Latin America and the Caribbean (24%) and Asia (23%). One in four women in Asia (27%) and Africa (25%) said that they, their husband or both were opposed to contraception, but just one in nine women in Latin America and the Caribbean (11%) gave this reason.

Only 4–8% of women in the three regions attributed their nonuse to lack of access to contraceptives, but this reason was mentioned by 15% of women in Middle Africa and 10% of those in Western Africa. Similarly, while 10–13% of women in those two subregions said that they were unaware of any contraceptive methods, only 1–6% of those in the three main regions and in other subregions cited this reason.

Some reasons were cited particularly often in certain countries. Infrequent or lack of sexual activity was mentioned by 73% of women in Nepal and 58% of those in Bangladesh. Side effects and health concerns were an issue for half of women in Haiti and Cambodia (51% each), and opposition to contraception was a reason for nonuse for substantial proportions of women in Timor-Leste (68%), Pakistan (49%), Tajikistan (45%) and Haiti (36%). About one in five women in Benin, Congo, Cameroon, Côte d’Ivoire and Guinea (18–23%) said that lack of access contributed to their nonuse.

Additional analyses suggested that many of the women who were not using contraceptives because they considered themselves to have little or no risk of pregnancy were by no means completely protected against conception. For example, although women who cited infrequent or no sex as a reason for nonuse were less likely than other women to be sexually active, in 21 countries more than half of such women had had sex in the past three months. Moreover, in 43 countries, fewer than half of women who gave postpartum amenorrhea or breast-feeding as a reason for nonuse had had a birth within six months and had indicated elsewhere in the survey that they were amenorrheic, suggesting that many were once again fertile.

Limitations of the study, according to the authors, include insufficient data for Latin America, the Caribbean and parts of Asia, the exclusion of countries without a DHS study (such countries might have lower levels of unmet need than do the countries included in this analysis) and the focus on married women. Nonetheless, a comparison between this study’s findings and those from an analysis of DHS data from 1995–2005 indicates that barriers to access have become a less important reason for lack of contraceptive use, whereas infrequent sex (especially in Asia) and concern about side effects and health have become more important; these trends, the researchers say, suggest that although some nonusers may have a relatively low risk of unintended pregnancy, others might benefit from contraceptive services that counsel women about a range of contraceptive options. They conclude that “improvements in the quality of programs and services can go a long way toward addressing many of the concerns identified in this study,” and recommend that future research examine levels of and reasons for nonuse among unmarried women and across population subgroups.

P. Doskoch

REFERENCE

1. Sedgh G and Hussain R, Reasons for contraceptive nonuse among women having unmet need for contraception in developing countries, Studies in Family Planning, 2014, 45(2):151–169.