An unmet need…
for a better measurement of contraceptive need
Mothers wait to receive family planning services at the Bako Clinic in West Shoa, Ethiopia. Photo courtesy USAID/Melesse Desalgn
Last week I attended an academic reproductive health meeting in which a well-meaning young researcher presented a graph showing knowledge of contraceptive methods and use of contraception among women in a low-resource country of Africa. Over 75% of the women in her study could name a method of contraception, but only 8% were actually using contraceptives.
Knowledge without use, the researcher stated, could be seen as high unmet need for contraception. The rest of the presentation was about their plan to use social media and opinion leaders to encourage women to use contraceptive methods.
After the presentation, a hand went up in the back of the audience. The comment was “let’s all agree to stop using the term ‘unmet need.’ It’s paternalistic.” The comment caused some hubbub in the audience, and I sensed widespread agreement that something was wrong with the way unmet need is measured and used.
The purpose in measuring unmet need for family planning services is to identify areas where women have poor access to family planning services. If women are sexually active, want to avoid pregnancy, and are not using a method of contraception, the thinking is that someone should make sure they have one. High unmet need has been a strong argument for increasing the availability of contraceptive supplies and improving distribution systems. And there is no doubt that funding for family planning services is far short of what it should be. See the Guttmacher Institute’s excellent report showing that doubling the global investment in family planning services would reduce maternal deaths by two thirds and infant deaths by half.
The problem with unmet need is not the words, which are not inherently paternalistic. The problem is with how it is measured. Never do the women themselves get to decide whether they need/want contraception. Instead, researchers use large surveys like the Demographic and Health Surveys to identify women they think need contraceptives (usually those who are sexually active and not actively seeking pregnancy). That’s the “need” in “unmet need.” In the classic formulation of unmet need, if women are currently using a method of contraception, their need is met.
Instead, unmet need should be defined as wanting to use contraception but not being able to. Taking the shortcut of not asking women what they want but instead presuming need is presumptuous, possibly paternalistic, and also results in poor allocation of resources.
There are many places with inadequate supplies of contraceptives, but the typical measure of unmet need would not effectively identify these places. Instead, places listed as having the highest unmet need are places where many women do not want to use a method. Why spend money to encourage women to use a method they don’t want to use, when there are plenty of places where women desperately want to use contraceptives but can’t?
It isn’t just a matter of effective distribution of resources. Pressuring women to use methods of contraception that they don’t want is coercive and likely counterproductive.
The other major shortcoming of the typical measure of unmet need is that simply using a method of contraception does not mean one’s contraceptive needs are met. Examining how satisfied women are with the methods they use and the hardships they face in getting an adequate supply could improve the quality and effectiveness of family planning services. Even among women who have access to contraceptives, there is widespread inconsistent and incorrect use. Supplies run out and a woman may have trouble using a method even when she wants it. She may not have ongoing support if problems arise during use. Addressing these unmet needs is as important as the unmet need to adopt a method.
Recommendations
A simple change in survey methodology and measurement would help direct resources to where they are most needed, facilitate quality improvement, and avoid facilitating coercive or wasteful programs.
- Create a woman-defined measure of unmet need.
- Ask women whether they would want to take a medication or use a device that prevents pregnancy. If they say no, ask them why.
- If they are using a method, ask them whether they are satisfied with the method, its use, and its availability.
This small change in methodology would vastly improve the effectiveness and acceptability of international family planning programs.
The concept of unmet need is not so much paternalistic in itself, as it is often applied to promote paternalistic, coercive, and authoritarian agendas. The nations that create and promote such agendas also determine the content and interpretation of the Demographic and Health Services which have the “unmet need for a better measurement . . . ” in the title of this post.
In thinking about a woman-defined measure of unmet need for contraception it is useful to refer back to a classic article on the topic:
DIXON-MUELLER, R. and GERMAIN, A. Stalking the elusive “unmet need” for family planning. Studies in Family Planning 23(5): 330-335. Sep.-Oct. 1992.
It is important to include all sexually active women in surveys — including those who are unmarried and young — and they should be asked not only about the contraceptive method they are currently using, but also about the characteristics of methods that they would prefer to use. It may be necessary to add quite a few more questions, but then the result would be a more useful measure of unmet demand for contraception.
Most importantly these questions should not be limited to national surveys, but an integral part of all health services. Males and females alike have to be asked about their sexual experiences and educated to ensure that they are not exposed to unwanted pregnancies or ill-sexual health. Thanks Diana for elaborating on the issue of “unmet need” and opening the discussion for researchers and clinicians.
I agree that we need better measures for unmet need. Yet the story is more complicated. To say a woman has knowledge of a method, does not necessarily mean she also has accurate information about that method. Women who know of a method, but choose to abstain may do so out of misinformation or fear of such side effects represent unmet need in a different sense. We often discuss at the Bixby Center for Population, Health and Sustainability how the DHS does not accurately capture women’s reasons for choosing not to use contraception, or at least not with enough detail for researchers and policy makers to really understand the challenges at hand. Therefore, as we aim to attain clearer measures of unmet need, I also think we need to better understand barriers, especially misinformation.
Top-down decisions about who ought to be using contraception but are not (i.e. “unmet need”) are offensive. But there’s another type of risk in Diana’s proposal: “unmet need should be defined as wanting to use contraception but not being able to”. We know from lots of research, not to mention the experience of health practitioners, that many women/men have concluded they should not use contraception because of health concerns, social concerns, etc. Some of this may be misinformation, or social pressures that result in decisions against their interest. If we only regard women/men who express a desire to use contraception as having “unmet need”, we may miss an enormous amount of unsatisfied need for contraception that is stymied by various non-access barriers.
I think a strength of the DHS approach to unmet need is that it is based on expressed preferences to avoid pregnancy (rather than an explicit desire to use contraception). It’s a further step to explore the reasons for discrepancy between preferences and contraceptive behavior. And this further exploration may reveal that some of the “unmet need” women/men should not be regarded as such.
It’s a question of false positive vs. false negative “unmet need” classification. Of course neither is desirable. I’d prefer risking false positive, at least when it comes to estimation of prevalence of unmet need from survey data. What happens at the clinic and provider level is an altogether different matter.
I totally agree with Karen that the DHS data on reasons for not using are inadequate. I can’t say with certainty that the DHS data have misled us badly. But I don’t think these data are a trustworthy basis for conclusions about the relative importance in different settings of the various barriers to use, and I’ve been dismayed to see them used for this purpose.
We need to be able to distinguish between current demand (women who want to use but can’t) and potential users (women or couples who want to delay or prevent pregnancy but don’t want to use contraception). Prioritization for funding, intervention strategies and effectiveness of increasing contraceptive supplies would differ greatly between these two groups.
Thanks, Diana, for elaborating on this idea from the meeting!
In general I have tended to agree with John who says that actually “a strength of the DHS approach to unmet need is that it is based on expressed preferences to avoid pregnancy (rather than an explicit desire to use contraception).” But in a way that’s because ‘we’ (researchers? programmers?) feel we’ve hit upon the logical crux of contraception behavior: we “know” that women wanting to avoid pregnancy WOULD be using contraception if they could. Maybe we lack understanding of both the “would” and the “could” — our interpretations of desires and barriers are pretty rote no matter where we’re talking about (the generic “in rural areas, supply chain problems may result in stockout; for women with little education, health literacy may be low…”). But specific cultural and subcultural contexts may have a lot to tell us about why people feel they can’t be, shouldn’t be, or wouldn’t like using contraception.
Not to state the obvious, but this discussion in general and Karen’s comment in particular speaks directly to the need for ongoing qualitative research! (Of course I was going to say that.)
I find this conversation fascinating because I’ve been using unmet need data for years. Based on the comments above, it comes down to whether women “should” “would or “could” use contraception, and most of us probably agree that “should” is paternalistic or presumptuous. I sometimes talk about “unmet need” as “potential need” for family planning–if women were better educated about the risk of becoming pregnant, the pros and cons of different methods, what to do about side effects, etc. they might be more likely to act on their stated preferences. (Hopefully they would if they could.) But no one has brought up the “preference” part of the equation! What does it mean when a woman says she would “prefer” not to have any more children, or prefer to wait at least two years? The strength of that preference, or level of motivation, is vague and hard to measure. And yet motivation plays a major role in deciding to use FP. “Intention to use FP in the future” only partially gets at this issue. If anyone has ideas about how to better measure motivation, that would be interesting to hear about.