Suggested citation: Ropey, B., Ross, J., and Bhushan, I. Meeting unmet need: New strategies.Population Reports, Series J, No. 43. Baltimore, Johns Hopkins School of Public Health, Population Information Program, September 1996.

This report was made possible by support from G/PHN/POP/CMT, Global, US Agency for International Development, under the terms of Grant No. DPE-A-00-90-00014-00. The opinions expressed herein do not necessarily reflect the views of the US Agency for International Development or the Johns Hopkins University.

Ward Rinehart, Project Director, Population Information Program

Anne W. Compton, Deputy Director, Population Information Program, and Chief, POPLINE computerized bibliographic services

Hugh M. Rigby, Associate Director, Population Information Program, and Chief, Media/Materials Clearinghouse

Jose G. Rimon II, Deputy Director, Center for Communication Programs and Project Director, Population Communication Services, developing family planning communication strategies, projects, training, and materials

Population Reports (USPS 063-150) is published four times a year (September, October, November, December) at 111 Market Place, Suite 310, Baltimore, Maryland 21202-4012, USA, by the Population Information Program of the Johns Hopkins University School of Public Health. Periodicals postage paid at Baltimore, Maryland. Postmaster to send address changes to Population Reports, Population Information Program, Johns Hopkins University School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202-4012, USA.

Population Reports is designed to provide an accurate and authoritative overview of important developments in the population field. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the US Agency for International Development or the Johns Hopkins University.

This report was made possible by support from G/PHN/POP/CMT, Global, US Agency for International Development, under the terms of Grant No. DPE-A-00-90-00014-00. The opinions expressed herein do not necessarily reflect the views of the US Agency for International Development or the Johns Hopkins University.

The concept of unmet need points to the gap between some women's reproductive intentions and their contraceptive behavior (31, 46, 215, 234, 237, 238). In doing so, it poses a challenge to family planning programs: to reach and serve the millions of women whose reproductive attitudes resemble those of contraceptive users but who, for some reason or combination of reasons, are not using contraception (201).

Among the most common reasons for unmet need are inconvenient or unsatisfactory services, lack of information, fears about contraceptive side effects, and opposition from husbands, relatives, or others (see Chapter 2, Reasons for Unmet Need). While many women who are using contraception have similar concerns, the obstacles to contraceptive use may loom larger for women in the unmet need group, or their commitment to controlling their fertility may be less certain.

By responding to the concerns of women with unmet need, programs can serve more people and serve them better (69, 178). Programs can respond best if they have a strategy that focuses on women with unmet need as a distinct audience and clientele (66, 153, 170). To develop an unmet need strategy, programs need to:

(1) Understand the various reasons for unmet need, based on qualitative research and survey data;

(2) Determine the size and composition of the unmet need subgroups by analyzing survey findings and other data;

(3) Identify high-priority subgroups that the program will be best able to reach; and

(4) Design and deliver information and services to meet the specific needs of each selected subgroup.

An unmet need strategy does not replace efforts to serve current contraceptive users or to promote the benefits of family planning. In fact, an unmet need strategy can reinforce other strategies. By focusing more on people's needs, many activities that address unmet need also address contraceptive users. Also, an unmet need strategy may reach some women who are not using contraception because they currently desire pregnancy (245).

Unmet need is defined on the basis of women's responses to survey questions. Essentially, women who respond that they want to postpone or avoid childbearing and also report that they are not using contraception (including use by their partners) are defined as having an unmet need. Since 1984 the main information source for measuring unmet need has been the Demographic and Health Surveys (DHS). These surveys have collected comparable information on fertility and family planning in more than 50 developing countries through interviews with representative samples of women and, recently in some countries, of men as well (174).

In addition, the Family Planning and Reproductive Health Surveys (FP/RHS) have estimated unmet need in national surveys since 1985. While the FP/RHS formulation of unmet need is not strictly comparable with that used in the DHS, these surveys provide estimates of unmet need for some countries, principally in Latin America and the Caribbean, that have not been surveyed in the DHS (174).

Standard formulation of unmet need. The formulation of unmet need that has become the standard and is used most widely to measure unmet need was developed principally by Charles Westoff (see How the Unmet Need Concept Evolved). In this formulation the unmet need group includes all fecund women who are married or living in union—and thus presumed to be sexually active—who are not using any method of contraception and who either do not want to have any more children or want to postpone their next birth for at least two more years. Those who want to have no more children are considered to have an unmet need for limiting births, while those who want more children but not for at least two more years are considered to have an unmet need for spacing births.

The unmet need group also includes all pregnant married women whose pregnancies are unwanted or mis- timed and who became pregnant because they were not using contraception. Similarly, women who recently have given birth but are not yet at risk of becoming pregnant because they are amenorrheic postpartum are considered to have an unmet need if their pregnancies were unintended (234, 237, 238) (see Figure 1).

In DHS conducted since 1990, pregnant or amenorrheic women are considered to have an unmet need for limiting births only if they respond that their current pregnancy or recent birth was unintended and that they do not want to have any more children (237). This is a change from earlier DHS, made necessary because, in the version of the questionnaire used since 1990, many women, particularly in sub-Saharan Africa, indicated that they did not want more children but were pregnant or amenorrheic, but they also responded to another question that they wanted another child. This apparent discrepancy probably is due to ambiguous wording of the questionnaire (237). Women who give such apparently conflicting responses now are classified as having unmet need for spacing births.

In the standard formulation the unmet need group does not include pregnant or amenorrheic women whose current pregnancy or recent birth was intended, even if they do not want to become pregnant again right away. Also, women who became pregnant unintentionally because of contraceptive method failure are not considered to have an unmet need for family planning in general, although they may need more reliable contraception (238).

Expanded formulations. As Ruth Dixon-Mueller and Adrienne Germain have pointed out, the standard formulation does not identify the full extent of need for family planning (55, 56). The standard formulation may be taken to suggest that all women using any contraception, whether effective or ineffective, appropriate or inappropriate, have their contraceptive needs met. In fact, however, some contraceptive users could be considered to have an unmet need if they are using an ineffective method, using a method incorrectly, or using a method that is unsafe or unsuitable for them.

Karen Foreit and colleagues have called this broader formulation the unmet need for "appropriate contraception" (67). For example, contraceptive users may need a more appropriate method because their current method causes side effects or because they are using a method best suited to spacing births when in fact they want no more children (55).

In countries where many women use traditional methods of contraception, it may be more appropriate to define unmet need as including women using traditional methods, such as periodic abstinence and withdrawal, in addition to those using no method at all (27, 50, 132, 193). This is because contraceptive failure rates usually are particularly high for traditional methods (180). In countries where the prevalence of traditional method use is high, the FP/RHS include an expanded measure—"need for any or more effective contraceptive methods"—as well as a measure of unmet need for any contraceptive method (79, 101, 132, 192).

Others with unmet need. The standard formulation does not consider unmet need among unmarried women, including unmarried young adults, who are sexually active and at risk of unintended pregnancy. Because there probably is much unmet need among unmarried sexually active women, this is a serious limitation, as Westoff has observed (229). When only women who are married or living in union, rather than all sexually active women, are considered as the basis for measuring unmet need, the implication may be that other women do not need contraception (55). In fact, the level of unmet need among sexually active unmarried women may be higher than among married women. Sexually active, unmarried women—including not only the never-married but also the separated, divorced, and widowed—typically have an even greater stake in avoiding pregnancy than do married women, but in many countries they are less likely to use contraception (237).

While there is no generally agreed-upon concept of unmet need among men comparable to that among women, surveys could provide the basis for such a formulation (233). In the FP/RHS, for example, men are considered to have an unmet need if they are sexually active, their partners are fecund and not pregnant, and they do not want their partners to become pregnant, but neither they nor their partners use contraception (127, 132).

Assessing unmet need among young adults is particularly important. Family planning and other reproductive health care programs reach relatively few unmarried young adults, women or men (125, 134, 246). While in most countries only a minority of young adults engage in sexual activity before marriage (125), most who are sexually active have a clear need for contraception (25, 55, 134, 237).

Reflecting recommendations in the Programme of Action of the International Conference on Population and Development (ICPD), Cairo, 1994, Steven Sinding and Mahmoud Fathalla have suggested conducting "a new generation" of surveys that measure unmet need more broadly, including unmet need among people who already are using contraception but may be dissatisfied with their method (200). Such surveys would gather both quantitative and qualitative information about women's and men's reproductive intentions and contraceptive use, experience with side effects, discontinuation of contraceptive use, and other problems related to family planning. Such information could help extend the focus of unmet need from use of any contraception to the quality of care (200).

In 1992 Population Reports estimated the total unmet need at 120 million women, based on DHS and comparable surveys conducted between 1985 and 1991 (174). The new estimate is somewhat lower than the earlier one primarily because the 1992-93 National Family Health Survey of India, released in 1995 (93), revealed less unmet need in the world's second most populous country than estimated earlier based on data from other countries in the region.

Still, more married women with unmet need live in India than in any other country—about 31 million. Other countries with more than one million married women with unmet need, as reported in the DHS, are Pakistan at 5.7 million, Indonesia and Bangladesh at 4.4 million each, Nigeria at 3.9 million, Mexico at 3.1 million, Brazil at 3.0 million, the Philippines at 2.5 million, Egypt at 1.8 million, and Kenya, Tanzania, and Turkey at 1.1 million each. Also, Vietnam has an estimated 5.2 million women with unmet need (179). In China, the world's most populous country, there probably is little unmet need, given the high level of contraceptive use, at an estimated 83% of married women of reproductive age in 1992 (218).

Regional and national differences. In the developing world as a whole, excluding China, about 20% of married women of reproductive age have unmet need. There is wide variation in this percentage among regions and countries (see Tables 1 and 2). The level of unmet need is highest in sub-Saharan Africa, where in some countries one married woman in every three has unmet need. In most of these countries more married women have unmet need than are using contraception. Among other developing regions, levels of unmet need are similar. Because of the large population of Asia, however, by far the greatest number of women with unmet need live in this region (see Table 1).

Among countries surveyed by the DHS in sub-Saharan Africa, unmet need ranges from 15% in Zimbabwe to 37% in Rwanda. Among Asian countries surveyed, unmet need varies from 11% in Thailand to 32% in Pakistan. In North Africa and the Near East, unmet need is close to the 20% average for the developing world in every country except Turkey, where it is 11%—with Thailand's, the lowest level recorded. In 6 of the 11 countries in Latin America and the Caribbean surveyed by the DHS, unmet need is below 20%. In Bolivia, Ecuador, El Salvador, Guatemala, and Mexico, however, the level is between 24% and 29% (see Table 2).

According to the FP/RHS, in Latin America estimates of unmet need are (132, 174):

Belize 1991	26%	Jamaica 1993	13%
Costa Rica 1992	23%	Nicaragua 1992	24%
Ecuador 1994	14%	Panama 1985	13%
El Salvador 1993	16%	Paraguay 1995	12%

Unlike the DHS, FP/RHS estimates include unmarried women as well as those who are married or in union. In the FP/RHS unmet need is estimated as the percentage of fecund, sexually active women, regardless of marital status, who are not using contraception even though they do not currently want to become pregnant. Also, unlike the DHS, the FP/RHS definition of unmet need does not include women who are already pregnant unintentionally, nor can unmet need be divided into limiting and spacing components (174).

Expanded estimates. Estimates of the expanded unmet need for family planning range widely depending on the criteria used. The International Planned Parenthood Federation (IPPF) has estimated that in developing countries, among the 172 million women estimated to be using modern temporary contraceptive methods, 97 million—over one-half of all such users—probably will stop using the method for a reason other than becoming pregnant and thus could be said to have an unmet need (94). Including women using withdrawal or periodic abstinence who probably will be unsuccessful or dissatisfied increases the number by 14 million. Thus the IPPF estimates that 111 million of the 200 million current users of temporary methods could have unmet need by this expanded definition.

Women using withdrawal or periodic abstinence as their contraceptive method often face substantial risk of an unintended pregnancy (180). For example, in the Philippines 33% of couples relying on periodic abstinence and 44% using withdrawal become pregnant within 12 months (56).

Where many couples rely on traditional methods, their inclusion raises the unmet need figure substantially. In Romania 43% of married women use withdrawal or periodic abstinence. Just 10% of women have unmet need in the sense that they are not using any contraceptive method, but 39% have unmet need if the criterion is not using a modern method (132, 192).

Similarly, an analysis of the 1987 Sri Lanka DHS found that, if the 21% of currently married women using traditional methods are all assumed to have unmet need, the level of unmet need among married women ages 15 to 49 would increase from 15% for any method to 31% for a modern method (50).

Estimates for unmarried women and for men. As the ICPD Programme of Action recognized, unmet need probably is substantial among the "growing numbers of sexually active unmarried individuals" (217). To estimate unmet need among never-married women, Westoff and Akinrinola Bankole examined data from 19 sub-Saharan African countries, where the DHS asked never-married women about their reproductive attitudes, sexual activity, and contraceptive use (237). Unmarried women cannot be presumed to be sexually active. Thus Westoff and Bankole consider fecund never-married women to have unmet need only if (1) they report that they were sexually active within the month before the survey and (2) they do not desire pregnancy but (3) they are not using contraception or else are pregnant unintentionally or amenorrheic after an unintended pregnancy.

By this definition, in the 19 countries studied unmet need among never-married women ages 15 to 49 ranges from 2% in Burundi and Mali to 16% in Namibia. The researchers also estimated levels of unmet need for never-married women by an expanded definition that includes those who have ever had sexual experience, whether or not in the past month. By this definition unmet need among never-married women is over 20% in 10 of the 19 countries, reaching 29% in Ghana and Zambia (237).

To estimate unmet need among young adults, Westoff and Bankole also reported on all women ages 15 to 19, whether married or not. Under the criterion of sexual activity during the month before the survey, in this group more women have unmet need than use contraceptives in 15 of the 19 countries studied (237).

Surveys are beginning to collect information on reproductive attitudes and contraceptive use among men. For example, in the 1993 Jamaica Contraceptive Prevalence Survey (CPS) unmet need among men is estimated at 20%, according to the formulation used in the FP/RHS (127) (see Others with unmet need in Chapter 1.1).

While DHS data do not yield estimates of unmet need among men, in a DHS Comparative Study, in 8 of 13 countries studied, the percentage of married men who do not want any more children exceeds the percentage using contraception (including use by their wives) (61). The Population Reference Bureau, using DHS data from six countries, estimates that one-quarter to two-thirds of husbands do not want to have more children but are not using contraception (157).

While evidence is limited, some level of unmet need is likely to exist in every country, developing and developed alike, even where family planning is widely used (2, 39, 148). For example, in the United States it was estimated that in 1988 about four million women, or about 7% of all women of reproductive age including unmarried as well as married, were not using contraception even though they did not want to become pregnant (29).

Most countries follow a similar pattern as they move through the demographic transition from high to low fertility. In general, a population passes through four stages, during which the level of unmet need first rises and then falls (238):

(1) High fertility. At first there is neither much contraceptive use nor much unmet need because most couples do not want to, or are unaware that they can, limit or space births. Fertility is high.

(2) Change in attitudes. As more couples want to control their fertility, unmet need rises because attitudes change faster than contraceptive use rises. Contraceptive use begins to rise as well, however, and the fertility rate starts to decline.

(3) Change in behavior. Reproductive attitudes continue to change and, as information and services respond to people's changing attitudes, contraceptive use rises rapidly, while unmet need declines. Fertility often declines rapidly.

(4) Lower fertility. Finally, most women do not want more children, and use of family planning is widespread. There is little unmet need remaining. Fertility stabilizes at a lower level than before.

Recent survey data illustrate this pattern among countries at different levels of contraceptive use (see Figure 2). In countries with high contraceptive prevalence, the level of unmet need is low. At lower levels of contraceptive use, the level of unmet need is high, with slightly lower levels of unmet need in countries with the very lowest levels of contraceptive use. Even in these countries, however, the levels of unmet need suggest that a transition is starting.

Recent change. How have levels of unmet need changed in recent years? Only 10 countries have conducted two DHS since 1985 with which to measure unmet need comparably. In each of these countries the percentage of women with unmet need declined between surveys. In seven—Colombia, the Dominican Republic, Egypt, Ghana, Indonesia, Kenya, and Morocco—the decline has been slight. In the other three the decline has been substantial, at 12 percentage points in Bolivia and Peru and 7 in Zimbabwe (see Table 3). Meanwhile, the level of contraceptive use stayed about the same in Indonesia and Colombia and grew appreciably in the other countries.

Among five countries in Latin America and the Caribbean that conducted two FP/RHS since 1986, the level of unmet need dropped substantially in four (132, 174):

Costa Rica	1986 1992	3% 3%	Jamaica	1989 1993	20% 13%
Ecuador	1989 1994	25% 14%	Paraguay	1987 1995	33% 13%
El Salvador	1988 1993	30% 16%

Westoff and Luis Ochoa studied changes in the percentage of women with unmet need, although only for limiting births, over a longer period by comparing 13 countries surveyed by the World Fertility Survey (WFS) in the late 1970s and again by DHS in the late 1980s (238). In the two sub-Saharan countries studied, Ghana and Kenya, unmet need for limiting had increased; it had more than doubled in Kenya. Unmet need for limiting had declined in all other countries—Egypt, Morocco, and Tunisia; Indonesia, Sri Lanka, and Thailand; and Colombia, the Dominican Republic, Ecuador, Mexico, and Peru.

Abortion statistics have been described as indicating the "ultimate unmet need for family planning" (44). Only a minority of women having abortions have used effective contraception. For example, in Thailand fewer than 30% of women hospitalized for abortion complications had ever used a modern contraceptive method (107). In Vietnam only 20% to 30% of women undergoing legal abortions had ever used modern contraception (80). In Zambia only 27% of women requesting legal abortions had ever used modern contraception, and only 12% of women treated for complications of unsafe abortions had ever used contraception (113).

While not all women who have had abortions would use contraception, many would be likely to do so. For example, in Nigeria among women hospitalized for abortion complications, only 10% had ever used contraception, but 45% said that they wanted to do so (144). In Bolivia only 7% of women hospitalized for abortion complications had ever used contraception, but 77% said that they wanted to do so (12).

While the term "unmet need" may evoke the image of women seeking contraceptives, Rodolofo Bulatao has observed, "the reality is that many of those counted as having unmet need still need to be convinced that contracepting is acceptable and in their interests" (31). To avoid misinterpretation, Bulatao has suggested substituting the term "blocked fertility preferences" to describe the women who want to control their fertility but "for some reason--internal or external, psychological or social or physical--are not taking steps to do so" (31). (Because the term "unmet need" has become widely used and accepted, Population Reports uses it throughout.)

Changing attitudes and behavior. While unmet need may not equal demand for contraception, it can be considered an "essential step" between preferring lower fertility and acting on this preference by using contraception (70). Adopting a new behavior such as family planning is not an instantaneous act but a process, as people become increasingly aware and interested and, eventually, decide to adopt and to maintain a new behavior (128, 162, 176). "Unless we assume that the gradual development of a new value--wanting fewer births--is immediately followed by the adoption of birth control, we can expect a group to exist with discrepant goals and means," Freedman and Lolagene Coombs observed in 1974. "This should be a group with a high potential for adoption of contraception" (73). That is, unmet need is a stage between changing attitudes and changing behavior (19).

Based on a review of studies over the past two decades, Freedman in 1996 concluded that family planning programs have played an important role in helping women move from having an unmet need to being contraceptive users. Programs help convert "what are often somewhat uncertain and ambiguous desires not to have more children into a definite demand for contraception." In other words, they help women with unmet need overcome barriers to contraceptive use, "thereby converting latent to manifest demand for contraception" (70).

Reasons for Unmet Need

Several reasons together explain why many women who would prefer to avoid pregnancy nevertheless do not use contraception, according to findings from comparable surveys and in-depth studies (see Exploring the Reasons for Unmet Need) (19, 25, 37, 165, 188, 196, 204, 237). These reasons are:

• Difficulties with access to and quality of family planning supplies and services;
• Health concerns about contraceptives and side effects;
• Lack of information;
• Opposition from husbands, families, and communities;
• Little perceived risk of pregnancy.

As family planning services have become widely available in many countries, however, recent studies using DHS data report that the distance to a source of contraception—measured by how far the average person lives from the nearest service site—now has little relationship to the level of unmet need in a country (25, 237, 242).

Even if distance to any service site may not be important to unmet need, lack of access to people's preferred methods and services can be a formidable obstacle (25, 213). For example, in a 1987 study of unmet need in South Korea, Kye-Choon Ahn and colleagues noted that, since family planning services had been available virtually throughout the country for more than 20 years, lack of services no longer explained unmet need. Dissatisfaction with the available contraceptive methods was more important (2). In Uttar Pradesh, India, a study found that little of the considerable interest in contraception for spacing births was being met because the family welfare program gave little attention to temporary methods such as oral contraceptives (53). Also, injectables are not available.

Satisfying people's various contraceptive needs requires a range of contraceptive methods. Thus the more contraceptive methods available in a country, the lower the level of unmet need (see Figure 3). A study of DHS data from 44 countries found that, for each additional contraceptive method that is widely available in a country, contraceptive prevalence increases by an average 3.3 percentage points. More than half of this increase, or over 1.7 percentage points, comes from meeting unmet need. This study controlled for the effects of economic development by using each country's score on the UN Human Development Index as a factor in the analysis (19).

An earlier study of DHS data, which also controlled for the effects of development, found that wide distribution of each new contraceptive method raised contraceptive prevalence by six percentage points. This study did not examine how much of the increase came from meeting unmet need (97).

In addition to lack of preferred methods, various other "costs" limit access to family planning. Many potential clients do not use contraception because of "monetary, psychological, physical, and time-related costs," Martha Ainsworth reported in 1985 on the basis of CPS data (3). Analyzing DHS data, John Bongaarts and Judith Bruce observed in 1995 that difficulties obtaining "adequate services that can be used without undue personal costs—psychological costs, travel time, monetary outlay, and so forth"—are reasons for much unmet need (25).

Poor-quality services—or the expectation of poor services—keep some women from using family planning. Some have been poorly treated at family planning clinics or have had problems with services (10, 54, 165, 190, 204). Sometimes, lack of supplies in clinics causes women to discontinue contraceptive use (138). Other women do not go to clinics because they fear modern medicine and are suspicious of service providers (188).

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).

The more contraceptive methods that women know, the lower their level of unmet need, as DHS findings illustrate (19) (see Figure 4). In> the Dominican Republic, for example, among women who know three methods or fewer, unmet need is more than twice as high, at 35%, as among women who know six methods or more, at 14%. A study using DHS data from Egypt and controlling for the effect of other factors on contraceptive use found that women who knew of more contraceptive methods were less likely to have unmet need (18).

Whether or not a woman knows of just one contraceptive method makes little difference to unmet need, however. In most countries outside sub-Saharan Africa, a large majority of people are aware of at least one contraceptive method—not only contraceptive users but also women with an unmet need (37). As might be expected, lack of awareness of any contraceptive method is most likely to explain unmet need in countries with little contraceptive use, as in sub-Saharan Africa (237). This is because, if a woman does not know about contraception itself, she cannot cite other reasons for not using it, such as lack of availability or side effects.

Just knowing that methods exist may not be enough information for many women. In-depth studies show that many women may be aware of at least one, and often several, contraceptive methods, but they often do not know how the methods work, what their side effects are, how to obtain them, how much they cost, whether their use can be kept private, and other aspects that may affect the decision to use contraception (35). Even when women give interviewers such reasons for nonuse as dislike of contraception, fear of side effects, or belief that they cannot get pregnant, these reasons suggest a lack of information about reproduction and contraception (98). In interviews and focus-group discussions, many women who are not using family planning "seem overwhelmed, and therefore demoralized, by what they do not know about contraception" (35).

Along with other reasons, lack of sufficient knowledge may contribute to more than two-thirds of all unmet need, Bongaarts and Bruce have estimated from DHS data for 12 countries (25). The researchers created a "knowledge index" consisting of three items: (1) mentioning a modern contraceptive method without being prompted; (2) being aware of its source; and (3) having an opinion about its side effects. In general, the level of unmet need is lower in countries where this knowledge index is higher. In five of the six sub-Saharan countries studied and in Peru, fewer than half of women with an unmet need could mention even one method, identify its source, and discuss its side effects (25).

Knowledge of availability. To use contraception, women must not only know about the existence of contraception itself but also what services are offered where and when. Studies have shown that the more women find contraception to be available, the more likely they are to use it (51, 147, 215). In general, women with an unmet need perceive family planning services to be less accessible than do contraceptive users, according to DHS data (19). WFS data for Nepal in 1979 showed that the level of unmet need for limiting in Nepal was lower among women who knew of a nearby service delivery outlet than among those who knew only a distant outlet (175). Similarly, in South Korea in 1974, 85% of women who did not know where to obtain contraceptives had unmet need. By comparison, 45% of women who said that they knew a source had unmet need. Perceived availability was more important to the level of unmet need than was women's education or residence (210).

Opposition from husbands. Many women do not use contraception because their husbands are opposed (37, 47, 165, 184, 188, 204). In seven sub-Saharan countries contraceptive use among women whose husbands disapprove of family planning averages only one-third as much as among women whose husbands approve of it (25).

From the limited evidence available, only a minority of all wives and husbands appear to disagree about using contraception. Nevertheless, these couples probably make up a substantial share of couples with unmet need (20, 37). In Kenya, among women who had stopped using contraception for reasons other than having another child, 12% had stopped because their husbands wanted another child or had forced them to discontinue for another reason (63). In the Philippines researchers found that the husbands of women with unmet need are much more pronatalist than the husbands of contraceptive users (37). When husbands want to have more children than their wives, the preference of the husband usually prevails (114, 121, 137).

Men's reasons for opposing family planning vary. Some want more children. Others oppose contraception, even if they do not want to have more children, because they worry that their wives might be unfaithful if protected from pregnancy (10, 40, 188). Others are jealous that male physicians would examine their wives (139). Still others want to control their wives' behavior, have religious objections, or fear the side effects of contraception (10, 37, 54, 184, 188). Husbands' attitudes may affect not only whether or not wives use contraception but also the choice of a method and how long it is used (99).

Husbands' opposition can have serious consequences. For example, in Guatemala one woman told researchers that she had been using oral contraceptives without her husband's knowledge, but when her husband discovered them, "he told me that I was using them because I had a lover. But I was doing it because I wanted to avoid suffering. But his beatings were greater than that" (10). In Tamil Nadu, India, T.K. Ravindran reported that women whose husbands oppose contraceptive use "may resort to abstinence under one pretext or another and, if pregnant, resort to a back-street abortion rather than face disapproval and discredit" (165).

According to DHS data, women with unmet need are much less likely than contraceptive users to believe that their husbands approve of family planning. For example, in Botswana only 47% of women with an unmet need think that their husbands approve of family planning compared with 82% of contraceptive users. In Pakistan the difference is even more striking—32% compared with 83% (see Figure 5).

Also, women with unmet need are much less likely than contraceptive users to have talked with their husbands about family planning. For example, in Ghana only 44% of women with unmet need had discussed family planning with their husbands in the preceding year compared with 72% of contraceptive users (see Figure 6). In India the level of unmet need for limiting births was significantly lower among couples who had discussed family planning than among those who had not, but discussion made little difference to unmet need for spacing (163)—possibly because temporary methods were not readily available. Such findings do not indicate whether discussion leads to contraceptive use or vice versa. It may be that, when woman use contraception, they are more likely to discuss family planning with their husbands. It could also be, however, that discussion makes it more likely that women can use family planning with their husbands' cooperation.

Opposition from families and communities. Although less important than husband's opposition, lack of support by extended families and community leaders also prevents some women from using contraception. In the Philippines, for example, women with unmet need are less likely than contraceptive users to consider contraception socially acceptable (37). In Kenya mothers-in-law prevent some women from using contraception because they think that it would weaken the control of the husband's family or that their daughters-in-law should not expect anything different from their own experience (184).

In most countries religious opposition is not an important reason for unmet need (237). In a few surveyed countries, however—including Bangladesh, Nigeria, Pakistan, and Senegal—religious opposition is one of the main reasons that women give in the DHS. In each of these four countries more than 10% of women with unmet need who do not intend to use contraception cite religious objections (237). In the study of Trishal, Bangladesh, only about half of women with unmet need thought that their religion approved of family planning compared with nearly three-quarters of contraceptive users (see Table 4).

Women with unmet need for limiting births are much more likely than potential spacers to think that they face little risk of pregnancy—probably because most women with unmet need for limiting are older. Among limiters who do not intend to use contraception, for example, 32% say that they are not exposed to the risk of pregnancy compared with only 15% among spacers (see Figure 7).

While many women may be right about their inability to conceive, other women face a risk of unintended pregnancy because they do not understand the menstrual cycle or do not know about reproductive physiology in general (38, 92, 164, 166, 203, 222). In Jamaica, for example, the 1993 RH/FPS found that only 30% of women of reproductive age knew when, during the menstrual cycle, that pregnancy is most likely (126). Among Jamaican students, the answer most frequently chosen to all questions about reproduction was "I don't know" (58). In Nigeria a study of women who had had abortions found that virtually none could identify the "safe period" of the month (59).

To an unknown extent, these contradictory responses may reflect difficulties with the survey questions (53). Nevertheless, in most countries surveyed more women fit this category than cite lack of information or disapproval of family planning as their main reason for not intending to use contraception.

Such apparently ambivalent responses are much more common among potential spacers than limiters. In fact, in the DHS it is by far the most important reason among potential spacers for not intending to use contraception (237). For example, in 24 countries, among spacers who do not intend to use contraception soon, an average of 37% appear ambivalent about their childbearing plans. Among limiters, 7% are ambivalent (see Figure 7). Ambivalent responses are common in sub-Saharan Africa, where most unmet need is for spacing births, but such responses are relatively rare elsewhere, where unmet need for limiting births typically accounts for a larger share of unmet need (237).

In some DHS conducted between 1985 and 1990, respondents were asked whether they would be "happy, unhappy, or indifferent" if they became pregnant within the next few weeks. In each of 13 countries analyzed, some women classified as having unmet need nonetheless said that they would be happy to become pregnant soon. The statistics differ sharply depending on whether the unmet need is for limiting or for spacing births. Just 10% or less of potential limiters said they would be happy to become pregnant soon compared with 30% to 50% of potential spacers (19).

Women's conflicting statements about their reproductive desires also may reflect the contradictions that they face in many aspects of their lives. In Guatemala, for example, some women interviewed said that they would prefer not to have any more children so that they could have more time for themselves, but also they wanted to have more children to please their partners (10). In Tamil Nadu, India, Ravindran found that few women had a clear view of how many children they wanted or even whether they wanted more children. "To engage in planning their families when nothing else about their lives seemed plannable may have been difficult," she observed (165).

Who Has Unmet Need?

Levels of unmet need vary substantially according to women's demographic and social characteristics such as their age and education. Also, there are important differences among women with unmet need—for example, whether their interest is in limiting or spacing births, and whether or not they intend to use contraception. Knowing which women are likely to have unmet need and the characteristics of these women can help family planning programs design unmet need strategies (see Chapter 5).

The major source of comparable information on unmet need by women's characteristics is the DHS. More detailed information from the DHS is available in Unmet Need: 1990-1994 by Westoff and Bankole, for 27 countries surveyed between 1990 and 1994 (237), and in Unmet Need and the Demand for Family Planning, by Westoff and Ochoa, for 25 countries surveyed between 1985 and 1990 (238).

Time since previous birth. Fecund, sexually active women who do not use contraception are likely to have frequent pregnancies, whether they want to or not (183). Thus levels of unmet need are highest among women who have given birth within the last three years. The level of unmet need drops dramatically as the interval since a woman's last birth lengthens.

Data from the 1993 Kenya DHS illustrate this pattern: Most women with unmet need have given birth within the previous 12 to 23 months, while only a few have a birth interval of more than 48 months (see Figure 8). Women classified as having an unmet need who have long intervals since their last births probably are less fecund and less sexually active than others with unmet need. Most of these women are older, with older children. Their numbers are few compared with the large numbers of younger women with unmet need.

Women's age. Almost everywhere, clear relationships emerge between women's age and the level of unmet need when unmet need is divided into its spacing and limiting components. Most unmet need among younger women, like most contraceptive use, is for spacing births, because younger women still want to have more children. Among older women most unmet need (and most contraceptive use) is for limiting births because older women have had as many children as they want, and often more (237). Unmet need for limiting typically peaks among women in their late thirties or early forties and then declines in the 45-49 age group, as in Kenya (see Figure 9). Many women in their forties have become infecund and thus are no longer included in the unmet need category.

Number of children. In developing countries almost all married women want to have children, and they want them soon after marriage. Thus among childless married women there is almost no unmet need for spacing or limiting births. Once women have had their first child, however, unmet need for spacing in some countries decreases with each additional child, while in other countries it peaks after the birth of two children and then decreases with each additional child. In almost all countries unmet need for limiting births increases with each additional child that a woman has. Overall, the trend for limiting and the trend for spacing cancel each other out. As a result, there is no apparent relationship between number of children and the overall level of unmet need (237, 238).

Education. There are two patterns of unmet need related to women's education (18, 237). Outside sub-Saharan Africa better educated women have somewhat less unmet need than women with little or no education, as in Turkey, for example (see Figure 10). In contrast, in most sub-Saharan countries, such as Ghana, levels of unmet need are about the same regardless of women's education levels.

These patterns suggest that outside Africa, although many women at all education levels want to avoid pregnancy, less educated women face more obstacles to using contraception than more educated women. In sub-Saharan Africa, however, women with more education are more interested in avoiding pregnancy than other women but face the same obstacles as other women.

Rural or urban residence. In most countries unmet need is greater in rural areas than in urban areas. In sub-Saharan countries, however, unmet need is either greater in urban areas or about the same as in rural areas (237, 238). In sub-Saharan Africa the pattern of unmet need by residence probably reflects both the greater interest in avoiding pregnancy among urban residents and the limited availability and acceptability of contraception, even in cities. Also, within cities everywhere, slum or squatter neighborhoods are likely to have higher levels of unmet need than elsewhere.

Pregnancy status. In surveyed countries an average of about one-third of all women with unmet need are pregnant or amenorrheic. The percentage varies by country, from 19% in Trinidad and Tobago to 65% in Rwanda (see Table 5). While such women are not immediately at risk of pregnancy, they are considered to have unmet need because their current pregnancy or recent birth was unintended or mistimed (237, 238).

The fact that many women with unmet need are pregnant or amenorrheic is closely related to the fact that unmet need is most common among women who have recently given birth. Fecund, sexually active women are likely to become pregnant soon if they do not use contraception. In a study of 33 countries, John Hobcraft found that 17% to 22% of pregnancies occurred within nine months of a previous birth (88). Many women give birth much sooner after the previous birth than they would like. In 25 surveyed countries an average of only 11% of women wanted another birth within two years after a previous birth, but 35% had given birth that soon (238).

Limiting or spacing. The distinction between unmet need for limiting and for spacing births is important for family planning programs. First, women who want to space births would be interested in temporary contraceptive methods, while women who want to have no more children may prefer long-term or permanent methods. Also, the main reasons for unmet need differ between potential limiters and spacers. For example, in the DHS, among women who do not intend to use contraception, apparent ambivalence is the most important reason among potential spacers, while few potential limiters appear to be ambivalent about their reproductive intentions. More than twice as large a percentage of potential limiters, however, do not intend to use contraceptives because they consider themselves not exposed to the risk of pregnancy (see Figure 7).

In most countries outside sub-Saharan Africa, unmet need is either greater for limiting than for spacing or is divided evenly between the two (see Table 2). In most sub-Saharan countries, however, there is little unmet need for limiting births. Women tend to want large families, or they may be reluctant to acknowledge to survey-takers that they would prefer not to have any more children. In sub-Saharan Africa most unmet need is for spacing births.

Previous use of contraception. Generally, most women with unmet need have never used contraception. In Guatemala, Madagascar, Mali, Niger, Nigeria, Pakistan, and Senegal, more than 80% of women with unmet need have never used contraception. Still, in some countries a substantial number have used contraception but have discontinued use, reflecting side effects, poor services, ineffective methods, or other concerns (see Chapter 2.2). The percentage of the unmet need group who have never used contraception ranges from 30% in Trinidad and Tobago to 88% in Niger (see Table 5). Such differences reflect differences among countries in levels of contraceptive use.

Intention to use contraception. Slightly over half of women with unmet need intend to use contraception within the next 12 months. This percentage varies widely among countries, however, ranging from 24% in Mali to 79% in Bangladesh (237) (see Table 5).

Women with an unmet need who intend to use contraception are different from those who do not. In a study of DHS data from Egypt, Jordan, and Morocco, John Stover and Laura Heaton found that intenders resemble contraceptive users, and nonintenders resemble nonusers, in such characteristics as ideal and actual family size, awareness of a contraceptive method, personal and husband's approval of family planning, discussion of family planning between wife and husband, and previous use of contraception. In particular, most intenders had used contraception before. Among women who did not intend to use contraception, nearly half appeared to face little risk of becoming pregnant (208) (see Figure 11). Recent research in Morocco found that most women followed up on their intentions to use—or not to use—family planning. In 1995 researchers surveyed some of the same women who had been surveyed in the 1992 Morocco DHS. Among women who said in 1992 that they intended to use family planning, more than 75% had done so by 1995. Those who had not done so were the most likely to have an unmet need for family planning in 1995. In contrast, among women who said in 1992 that they did not intend to use contraception, just under 30% had changed their minds and done so by 1995. When Sin Curtis and Charles Westoff took other influences on family planning use into account, women who intended to use contraception in 1992 proved to be more than twice as likely actually to have used contraception by 1995 as those who had not intended to use it. As a predictor of contraceptive use, intention to use was second only to previous use of a method (48).

Thus women who intend to use family planning in the future, even if they have no unmet need now, probably would respond better to family planning program efforts than women at risk who do not intend to use contraception (48, 53, 108, 153, 207, 236). Research in Nepal, for instance, has found that women with unmet need who intend to use contraception are more likely than nonintenders to view family planning and health workers favorably (207). In contrast, many nonintenders may not feel strongly about avoiding pregnancy or may face little risk of pregnancy. In Morocco, among women who in 1992 had an unmet need but did not intend to use contraception, most responded in 1995 either that they wanted to have more children or that they were not likely to get pregnant (48). Low risk of pregnancy is often an important reason for nonuse among women presumed to have unmet need. In some countries—including Bangladesh, Burkina Faso, Egypt, Ghana, Jordan, Turkey, and Zambia—the DHS find that one-third to one-half of all women with unmet need say that they face little risk of becoming pregnant because they are old or hardly ever have sexual relations (238).

Many women who are not using contraception and do not currently have unmet need—that is, women who presumably are trying to have a child—say that they intend to use contraception in the future. For example, in each of eight countries in Africa, Asia, and Latin America studied using DHS data, the number of women without current unmet need who report that they intend to use family planning equals or exceeds the number with unmet need who do not intend to use family planning (179).

Interest in family planning is substantial even when the comparison is limited to intention to use contraception within the next year. Among 16 countries from all regions of the developing world, in 7 countries the number of women without unmet need who intend to use contraception in the next year equals or exceeds the number of women with unmet need who do not intend to use contraception in the next year. In 12 of the 16 countries, at least half of all women without unmet need intend to use contraception within a year.

Similarly, in Bangladesh 12% of married women are not using contraception and want a child in the next two years—thus they do not have unmet need—and yet they intend to use contraception within the coming year. Apparently, they anticipate needing family planning. Again, this group is equal in size to the group of women with unmet need who say that they do not intend to use family planning (13). Such findings suggest that "a large reservoir" of potential interest in family planning exists beyond women with unmet need (179). In terms of personal characteristics, these women resemble those with an unmet need for spacing (179). They may respond as readily to unmet need strategies as women who currently have unmet need.

Program Implications

In general, the reasons for unmet need suggest that three approaches should be part of most unmet need program strategies:

• Maximize access to good-quality services;
• Emphasize communication; and
• Focus on men as well as women.

Exploring the Reasons for Unmet Need

Thus interest has grown in conducting more small-scale, qualitative studies that use in-depth interviews and focus-group discussions to reveal attitudes, interests, and values that help to explain unmet need (169). In general, public health programs increasingly are using such studies to provide psychosocial data—or "psychographics," a term borrowed from advertising and marketing research (26, 68)—in order to add "color and depth" to data from large-scale surveys (153).

"Main" Reasons Identified by the DHS

Nearly two of every three nonintenders queried in 24 DHS surveys since 1990 give reasons that fit one of three main categories: lack of information; opposition to family planning; or apparent ambivalence about future childbearing. Other reasons include fear of side effects, little exposure to the risk of pregnancy, and unavailability of contraception (237). The mix of these reasons differs by whether unmet need is for limiting or spacing (see Limiting or spacing in Chapter 3.2 and Figure 7).

In contrast, the DHS questionnaire used from 1985 to 1990 asked women with an unmet need their main reason for not currently using contraception. Women queried about current use were more likely to cite husband's disapproval and health concerns than the women asked about their intentions. Women asked about current use also were less likely to disapprove of family planning or to give conflicting answers about childbearing desires (25).

Insights from Qualitative Studies

The Philippines. In Manila and several rural areas, women with unmet need were more likely than contraceptive users to think that the health risks of contraception outweigh the risks of pregnancy (37). Together, their fears of side effects and their husbands' fears explained much of the unmet need. Women with unmet need appeared less committed than contraceptive users to avoiding pregnancy. Also, they were less likely to think themselves at risk of pregnancy.

Nepal. In the Chitwan District, where access to services is better than in many other parts of Nepal, many women with unmet need said that they did not use contraception because they received or expected poor treatment at clinics, or they feared side effects of contraceptive use that would cost them time working (204). Many women with unmet need expressed concerns about their health and said that their husbands opposed family planning. Also, they were less likely than contraceptive users to have relatives or friends who were using contraception.

In Dang District, where family planning is not as accessible, some women were not using contraception because they did not know who could provide information and supplies (223). Others believed that they had to bear more children than they ideally would want because they expected some to die before they grew up. Also, women and men alike expressed reluctance to try contraception because they feared that other people would disapprove.

Guatemala. In a peri-urban neighborhood of Guatemala City, women said that uncertainties about the characteristics and safety of contraceptives, fear of side effects, and dissatisfaction with particular methods kept them from using family planning (10). Sometimes faced with sexual violence from their partners, many women deferred to the wishes of their partners despite their own preferences.

India. In two communities of Tamil Nadu, one peri-urban, the other rural, unmet need often resulted f