Women who never have used contraception. Most women with unmet need who cite a health concern about a particular method have never used that method themselves. Sometimes they have heard about medical problems that others experienced using contraception. In the Philippines women provided interviewers with detailed, often graphic descriptions of the health risks of using contraception—for example, of women who had been hospitalized because IUDs were incorrectly inserted (37). In Nepal women with unmet need told interviewers that they feared sterilization because they knew of women who had died of sepsis following sterilization procedures (204).

Sometimes people's fears are based on rumors. For example, a study among Aymara women in urban Bolivia found that almost all had heard alarming stories and "often fantastic" rumors about harmful side effects (188). In Kenya women in focus-group discussions spoke of pills accumulating into life-threatening masses in the stomach and other bizarre effects thought to accompany contraceptive use (184). In Nepal some women said that they would not consider sterilization because it was said to cause weakness and so require additional nutritious foods that they could not afford (196).

Rumors often have a basis in reality (139). Thus several reasons can combine to contribute to unmet need—poor-quality services or methods lead to real health problems that, in turn, become the basis for exaggerated rumors, which are spread and believed by many people who have little direct knowledge of contraception.

Women who have discontinued family planning. Many women have discontinued contraceptive use, not because they wanted to become pregnant, but because they experienced side effects and health problems attributed to contraceptives (180). In an analysis of DHS data from six countries, Mohammed Ali and John Cleland found that health concerns, including side effects, were the most common reason for discontinuation, even more common than desire for another child (4).

In some countries as much as one-fifth of unmet need follows discontinuation due to side effects, according to analysis of DHS results (19). Other research supports such findings. For example, in Nepal research by Douglas Storey and colleagues found that 15% of women in the unmet need group had discontinued use, slightly more than half of them because of side effects or health concerns (207). Another study in Nepal, where contraceptive prevalence in 1991 was just 23%, found that about one-quarter of the unmet need group had discontinued contraceptive use because of side effects (204). In Kenya most women who discontinued using contraception did so because they experienced side effects and could not find a different method (103). In Ghana health concerns and side effects were by far the most common reasons given for discontinuation among women who had used oral contraceptives but had stopped coming to family planning clinics (216). In Jordan women in focus-group discussions spoke of modern contraception mainly in terms of their side effects and health risks. Participants cited few examples of trouble-free use of IUDs or oral contraceptives, for example (247).

Discontinuation often leads to unwanted pregnancies. For example, in the Ghana study nearly half of the women who had discontinued use became pregnant within 32 months, and more than one-third of these pregnancies were unintended. Some 39% of these unintended pregnancies were aborted (216).

Comparing risks. Many women have concerns about contraceptive side effects and health risks (37). Many use contraception despite these reservations, however, because they see it as preferable to becoming pregnant. For example, in Mexico a study found that IUD users accepted side effects, including heavy bleeding, as the price of avoiding unwanted pregnancy (152). In Bangladesh women in focus-group discussions often spoke of the perceived dangers of contraceptive use but, as one woman told interviewers, "We opt for family planning along with the problems. It is better than to have a child" (197).

Other women, however, would rather risk an unintended pregnancy than use contraception, especially when they lack information about effects on health (54, 213). For example, in India women said that they did not know the health risks of using contraception and could not afford to risk becoming ill (165). In Kenya many women said that the risks of contraceptives were unfamiliar compared with the well-known risks of pregnancy and childbirth (184).