Estimates of unmet need for contraception calculated using only women’s reported fertility intentions and contraceptive use may not be representative of couples’ need. According to an analysis of Demographic and Health Survey (DHS) data from monogamous couples in three West African countries, the proportion of couples in which at least one partner reported having unmet need ranged from 31% to 37%.1 In fewer than half (41–49%) of such couples did both partners individually report having unmet need; unmet need was reported by the wife only in 33–40% of couples and by the husband only in 15–23%.
Typically, research studies on unmet need for contraception estimate levels among married women and assume that their reports about fertility intentions and contraceptive use represent those of couples. To directly examine rates of unmet need among couples, researchers used DHS data from three West African countries: Benin (2006), Burkina Faso (2003) and Mali (2001); West Africa was chosen because of its high level of unmet need, and the three surveys were used because they were the only ones available from West African countries with the measures to calculate unmet need among couples. The three surveys had a combined sample of 7,821 couples.
Unmet need for contraception was determined separately for women and men on the basis of their fecundity, contraceptive use and fertility intentions. Women who were currently pregnant or experiencing postpartum amenorrhea and who were not practicing contraception were considered to have unmet need if they reported that their current or last pregnancy, respectively, was mistimed or unwanted; other fecund women who were not practicing contraception were considered to have unmet need if they reported wanting to wait at least two years before becoming pregnant, not wanting any more children or being undecided about future childbearing. For men, unmet need was defined in a similar way, using their reports of their fertility intentions but their wife’s reports of fecundity, pregnancy and postpartum amenorrhea. Contraceptive use among women and men was based on a couple-level measure: A couple was considered to be practicing contraception if the wife reported use of a female-controlled method, the husband reported use of a male-controlled method or both.
Unmet among couples was based on the couple-level measure of contraceptive use; wives’ reports of fecundity, pregnancy and postpartum amenorrhea; and husbands’ and wives’ fertility intentions. Four categories of couples’ unmet need were created: neither partner has unmet need, only the wife has unmet need, only the husband has unmet need and both partners have unmet need. Categories that included at least one partner with unmet need were further divided by whether the unmet need was for limiting or spacing.
For their analytic sample, the researchers selected the 3,848 monogamous couples for whom complete fertility intention data were available; couples in which either partner reported being in a polygynous union or having had an extramarital relationship in the past year were excluded. Analyses examined levels of unmet need among wives, husbands and couples, as well as concordance of partners’ reports of unmet need within couples.
The levels of unmet need among wives and husbands were 24% and 21%, respectively, in Benin, 27% and 20% in Burkina Faso, and 30% and 22% in Mali. In all three countries, a greater proportion of unmet need was for spacing (16–24% among wives and 15–19% among husbands) than for limiting (6–8% among wives and 3–6% among husbands).
Overall, the proportion of couples in which at least one partner reported having unmet need was 31% in Benin, 32% in Burkina Faso and 37% in Mail; unmet need was reported by the wife only in 10–15% of couples, by the husband only in 5–7% of couples and by both partners in 14–16% of couples. Among couples with unmet need; 41–49% were concordant (that is, both partners reported having unmet need); the remaining couples had discordant unmet need, reported either by the wife only (33–40%) or the husband only (15–23%). In all three countries, the proportion of couples in which both spouses reported having unmet need for spacing was greater among couples with 0–4 living children (30–38%) than among those with five or more (8–16%), whereas the proportion of couples in which both spouses reported unmet need for limiting was greater among couples with five or more living children (17–33%) than among those with 0–4 (1–5%).
The study had several limitations, as noted by the authors. For example, more than half of couples were excluded from analyses because of polygamy or extramarital affairs, which limits the study’s generalizability. In addition, social desirability bias may have led to exaggeration of male-controlled contraceptive use and underestimation of husbands’ and couples’ unmet need. Furthermore, couple-level fecundity was determined using only wives’ reports, possibly underestimating husbands’ infecundity and overestimating couples’ unmet need.
Nonetheless, the authors conclude that determining unmet need solely on the basis of women’s reports overestimates concordant unmet need among couples. They suggest that more research is needed, which would require that "the same questions…be asked of men and women…so that couples’ unmet need can be assessed using DHS data in a wider variety of settings." They also suggest that "the DHS could improve researchers’ ability to explore [unmet need in polygynous settings] by systematically including questions directed toward men in polygynous unions concerning their contraceptive use with each partner and their fertility preferences with each partner."—J. Rosenberg
REFERENCE
1. Pearson E and Becker S, Couples’ unmet need for family planning in three West African countries, Studies in Family Planning, 2014, 45(3):339–359.