57924
Unmet need for contraception1
at a glance
The concept of unmet need children but are not using any form of fam-
ily planning (unmet need for contraception
for limiting) or currently married women
The concept of "unmet need for contraception", who want to postpone their next birth for
which refers to the proportion of women who do two years but are not using any form of
not want to become pregnant but are not using family planning (unmet need for contracep-
contraception, has been used in the international tion for spacing)[2]. The unmet need measure
population field since the 1960s. The concept was gives an estimate of the proportion of women who
developed from the first family planning and fertility might potentially use contraception. Women who are
surveys conducted in developing countries, which using contraceptives are said to have met need for
found a disconnect between women's knowledge, family planning. The total demand for family plan-
attitudes, and practices (KAP) about contracep- ning is made up of the proportion of married women
tion. This gap between what the respondents knew, with unmet need and married women with met need
their fertility preferences, and behaviors to achieve for family planning.3
their stated preferences, became known first as the
"KAP-Gap" and was used as a strong rationale for The existence of unmet need is sometimes interpreted
investment in family planning programs (Casterline as evidence of lack of access to a source of contra-
and Sinding, 2000)[1]. The subsequent development ceptive supplies. However, there are many reasons
of the unmet need concept has been supported by why women do not use contraception, and unmet
the availability of datasets from over 75 countries need should not be equated with the lack of access
collected by the Demographic and Health Surveys to contraception due to supply constraints (such as
(DHS) program. Difficulties with the measurement and distance to a source for obtaining contraceptives,
interpretation of the concept have been described in stockouts of contraceptives among providers, or legal
several papers by Westoff and coauthors since the obstacles), or to financial costs associated with using
1970s[2�6]. In this note, we summarize the strengths family planning. As assessed by surveys, women
and weaknesses of the unmet need indicator, discuss with unmet need may still not have any intention to
the differences between demand and supply factors use contraception were it readily accessible and of
for unmet need, show the differences between unmet good quality. Non-use of contraception may be due
need and the intention to use contraception, and to demand side reasons, including cultural or reli-
clarify the relevance of the concept for investing in gious objections to contraception, objections from a
family planning programs.2 spouse, lack of knowledge, or fear of side effects.
Unmet need for contraception is one of several In countries such as Niger or Nigeria, in which large
frequently used indicators for monitoring of family families are the norm and women do not want to
planning programs, and was recently added to the space or limit fertility, both contraceptive use and
MDG goal of improving maternal health. Some other unmet need are low (Figure 1). In countries in which
indicators that are used in combination with unmet
need are the contraceptive prevalence rate (CPR),
the method mix, sources of contraceptive supplies,
1
This note was written by Samuel Mills, Ed Bos, and Emi Suzuki, of the
Human Development Network at the World Bank. Correspondence
and reasons for not using contraception. In this note, to: smills@worldbank.org . Peer reviewer comments from John May
we deal mainly with the unmet need indicator, but (AFHTE) and Thomas Merrick (WBIHS) are gratefully acknowledged.
believe that other indicators should also be part of 2
This note will not review the extensive literature on the predictive
monitoring and evaluation of family planning pro- validity of stated reproductive attitudes and intentions on contraceptive
demand and reproductive behavior. See, for example, A. Bankole and C.F.
grams to broaden the understanding of the use of Westoff, The consistency and validity of reproductive attitudes: evidence
family planning in countries. from Morocco, J Biosoc Sci. 1998 (4):439�55; and T.K. Roy et al., Can
women's childbearing and contraceptive intentions predict contraceptive
demand? Family Planning Perspectives 2003, 29 (1): 25�31.
The indicator unmet need for contraception is 3
A better term would be "total market for family planning", as those
defined as the proportion of currently mar- with unmet need may not have a demand for contraception at the time
ried women who do not want any more unmet need is established.
March 2010
desired family size has been declin-
ing and couples want to space or limit Figure 1. Unmet need for family planning vs.
the number of children, as in Uganda contraceptive prevalence rate, 2000�2008 DHS
or Ethiopia, unmet need frequently reports, selected countries
increases. In these countries, informa-
tion on contraceptive methods, or 50
where to obtain them is incomplete, or
45
family planning services do not cover Uganda
the entire population. Over time, fam- 40
Unmet need for Family Planning
Rwanda Haiti
ily planning programs in countries with 35
Liberia Ghana
Ethiopia
declining desired family size (such as Mauritania
Senegal Lesotho
30 Mali Benin
Zimbabwe or Namibia) are often able Burkina Faso
Eritrea Congo Democratic
Gabon
Malawi
Zambia
Nepal
to improve supply of contraceptives 25
Median Unmet need=22
Republic Pakistan
Madagascar Kenya
Cambodia
Azerbaijan
Swaziland
Bolivia
and improve information on method 20 Chad Guinea Cameroon
Tanzania
Philippines
Namibia
availability and safety, leading to an Niger
Nigeria Mozambique Congo
(Brazzaville)
Bangladesh Honduras
15
increase in contraceptive use and a Armenia India
Zimbabwe
Jordan Ukraine Dominican
decline in unmet need. It is important 10 Morocco Egypt Peru Republic
Indonesia Turkmenistan
not to interpret high levels of unmet 5 Moldova
Colombia
Vietnam
need as the failure of a family plan-
0 Median CPR=44
ning program, as unmet need is a
dynamic indicator that changes from 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
low levels in countries in which fertility Contraceptive Prevalence Rate
preferences have not started to decline
to higher levels during the transitional
period between high and low fertility,
when the demand for contraception
has been created, and back to low levels as the of unmet need does not include an assessment of
demand becomes fulfilled. Trends in unmet need whether women want or intend to use contraception.
observed in countries will be discussed in section 6
below.
Reasons for unmet need
How unmet need is measured Knowing the level of unmet need in a given area
at a certain time does not by itself provide informa-
Unmet need for contraception is generally measured tion on why unmet need exists, or what the potential
with household surveys, in which married women of future demand for contraception might be. Women
reproductive age respond to a number of precisely may have one or more reasons for not intending to
worded questions. The steps involved in calculating use contraceptives which may be related to desired
whether unmet exists are illustrated in Figure 2, which fertility (wanting to have more children), to opposi-
shows a flow chart for how information is collected tion to contraception for cultural or religious reasons
used to calculate the level of unmet need. A woman (by women or their husbands, or others), to lack of
is first asked whether she is using any method of knowledge of methods or where to obtain them, or
contraception, whether for the purpose of limiting or to fear of side effects or health concerns. Knowing
spacing births. If she is using contraception, includ- why women have unmet need is useful when plan-
ing traditional methods, she is considered to be a ning information, education, and communication
contraceptive user, and therefore does not have (IEC) campaigns and behavioral change communica-
unmet need. Women who are not using contracep- tion (BCC) programs to generate demand for family
tion are then asked whether they are pregnant or planning services. For example, women with unmet
amenorrheic (not menstruating, often due to a recent need who are not planning on using contraception
pregnancy or lactation). In the calculation of unmet because of health concerns may be provided with
need, pregnant or amenorrheic women whose preg- information on several alternative contraceptive meth-
nancy was mistimed or unwanted are added to the ods or counseling on side effects. In contrast, women
proportion with unmet need, even though they do not with unmet need who want to use contraception in
at the time of the survey have an immediate need for the future may need information on where to go or
contraception, given their prgenancy. Women who need help with the cost of a contraceptive method.
are not pregnant or amenorrheic and are infecund
do not have unmet need, nor do women who want to The Demographic and Health Surveys asked the
become pregnant soon. Note that the measurement reasons for non-use of contraception of women who
2
Figure 2. The Measurement of unmet need among currently married women,
Zambia 2001�2002
Currently Married Women 100%
Using for Using for Not Using Any Method 66%
Spacing 19% Limiting 15%
Pregnant or Amenorrheic 33% Not Pregnant or Amenorrheic 33%
Intended 18% Mistimed 10% Unwanted 5% Fecund 24% Infecund 9%
Want Later Want No More Want Soon
6% 6% 11%
Need for Need for Need for Need for
Spacing 10% Limiting 5% Spacing 6% Limiting 6%
Total Unmet Need 27%
Source: Westoff 2006.
are not planning to use in the future.
Figure 3 shows the mean values for Figure 3. Reasons currently married women who
South Asian and Sub-Saharan African are not using contraception do not intend to use in
countries of all surveys conducted future, 2000�2008 DHS reports, regional means
from 2000 to 2008. For women
whose reasons for not using contra-
ception are not related to a desire to 54
Opposition to use
45
have more children or other fertility-
related reasons such as infertility
37
and infrequent sex/no sex, the most Health concerns/effects
39
important reasons are opposition to
use contraceptives, and a fear of side
5
effects and health concerns. Lack of Lack of knowledge
14
knowledge is somewhat important
in Sub-Saharan Africa; the costs of 4
contraceptives or access to a family Cost too much
1.2
planning provider are not important
reasons in either region. This indicates 0.4
Lack of access/too far
that family planning programs must 0.5
do more than supplying methods of
contraception at affordable prices. 0 10 20 30 40 50 60
An understanding of the nature of South Asia Sub-Saharan Africa
concerns of side effects, and the
reasons for opposition to use is critical Note: Fertility-related reasons such as wanting more children are excluded
to design appropriate communica-
3
tion campaigns. IEC efforts need to
address the reasons for opposition to Figure 4. Reasons currently married women
use (this could include opposition from who are not using contraception who do not
husbands or other family members, or intend to use in future, 2000�2008 DHS reports,
religious reasons), as well as provide selected countries
sufficient information so that women
can make informed choices about the
44
significance of side effects and poten- Opposition to use 35
tial health impacts. Such information 62
efforts need to take individual country
9
findings into account, as reasons for Health concerns/effects 58
not intending to use contraception 27
may vary substantially in different 45
socioeconomic contexts, as shown Lack of knowledge 5
10
in Figure 4. Lack of knowledge is the
most important reason for the inten- 1.0
tion not to use contraception in Chad, Cost too much 1.1
0.6
whereas this is unimportant in Ghana,
where health concerns and side 0.3
Lack of access/too far 0.5
effects are the reported reasons for 0.4
non-use. In Senegal, more than half of
all women who are not using con- 0 10 20 30 40 50 60 70
traception are not doing so because Chad Ghana Senegal
of opposition to family planning (the
exact nature of which is also collected Note: Fertility-related reasons such as wanting more children are excluded
in the DHS).
In most low- and middle income
countries, knowledge of contraceptive methods and cent (Middle East and North Africa) to 26 percent
where to obtain them is high for married women (Sub-Saharan Africa); met need (Contraceptive
of reproductive age (between 90 and 100 percent Prevalence Rate) ranges from 25 percent (Sub-
of survey respondents), but in a few Sub-Saharan Saharan Africa) to 63 percent (Latin America and
African countries (include Chad, Mali, Niger), knowl- the Caribbean).
edge of at least one contraceptive method is much The total demand for family planning across
lower (between 60 to 80 percent). In these countries, regions ranges from 51 percent (Sub-Saharan
both contraceptive use and unmet need are low, Africa) to 80 percent (Latin America and the Ca-
as the desired level of fertility is high. IEC efforts in ribbean). In Africa, only 45 percent of demand is
these countries need to focus on the potential benefits satisfied, contrasting to 70�84 percent in the other
of small family sizes and the untoward health effects regions.
such as low birth weight, preterm birth, high infant
In Sub-Saharan African countries, unmet need for
mortality, and high maternal mortality.
limiting is very low in Chad, Congo, and Niger
(below 5 percent); it is also low in Zimbabwe (5
Levels of unmet need in low- percent), where most of the unmet need has been
addressed through increased contraceptive use.
and middle income countries
Different levels of unmet need and total poten-
Table 1 shows the levels of unmet need in recent tial demand for family planning in Sub-Saharan
DHS country reports during 2000�2008, showing African countries reflect the non-linear pattern of
aggregate results for the Bank regions, and detailed unmet need over the fertility transition, pointing
country results for the Africa region. Some of the key to the need for careful interpretation of levels and
findings from this table include: trends of the unmet need indicator.
Unmet need is higher for limiting than spacing
childbearing, in all regions except Sub-Saharan
Levels of unmet need by
Africa, where unmet need for spacing is almost poverty quintiles
twice as high as for limiting
Across regions, unmet need ranges from 11 per- Unlike many of the other health indicators,
levels of unmet need do not show clear
4
Table 1. Unmet need, met need, and total demand for family planning. Countries
with DHS surveys 2000�2009 (unweighted means for regional aggregates)
Total
Unmet Unmet Unmet Met demand Percentage
need for need for need Need for family of demand
spacing limiting Total (CPR) planning satisfied
Region/Country A B C (=A+B) D E (=C+D) F (=D/E)
East Asia and Pacific 6 8 14 57 71 79
Europe and 4 9 13 60 73 83
Central Asia
Latin America and 7 10 17 63 80 77
Caribbean
Middle East and 4 7 11 57 68 84
North Africa
South Asia 8 12 20 47 67 70
Sub-Saharan Africa 17 9 26 25 51 45
Benin 18 12 30 17 47 36
Burkina Faso 22 7 29 14 43 32
Cameroon 14 6 20 26 46 56
Chad 18 2 21 3 24 12
Congo, Rep. 13 3 16 44 61 73
Congo, Dem. Rep. 19 5 24 21 45 46
Eritrea 21 6 27 8 35 23
Ethiopia 20 14 34 15 49 30
Gabon 20 8 28 33 61 54
Ghana 23 13 35 24 59 40
Guinea 13 8 21 9 30 30
Kenya 14 10 25 39 64 62
Lesotho 11 20 31 37 68 55
Liberia 25 11 36 11 47 24
Madagascar 11 12 24 27 51 54
Malawi 17 10 28 33 60 54
Mali 21 10 31 8 39 21
Mauritania 23 9 32 8 40 20
Mozambique 11 8 18 26 44 58
Namibia 9 12 21 55 76 73
Niger 13 3 16 11 27 42
Nigeria 12 5 17 15 32 46
Rwanda 25 13 38 17 55 32
Senegal 24 7 32 12 43 27
Swaziland 7 17 24 51 75 68
Tanzania 15 7 22 26 48 55
Uganda 25 16 41 24 64 37
Zambia 17 9 27 41 67 61
Zimbabwe 8 5 13 60 73 83
Source: Demographic and Health Surveys (2000�2009).
5
patterns by poverty quintiles
as shown in Figure 5. In some Figure 5. Unmet need by poverty quintiles,
countries such as Benin, Chad, Mali, 1990�2008
and Nigeria, women in the wealthi-
est quintile have higher unmet need 50
than the women in lower quintiles, 45
whereas in other countries such as
Bolivia, Ghana, Togo, and Zimbabwe, 40
the patterns are reversed. The rea-
Percent with unmet need
35
sons for these patterns are essentially
30
the same as for differences among
countries at different stages of fertil- 25
ity decline. Countries in which unmet 20
need increases with increasing wealth
tend to be in the earlier stages of 15
declining desired family size, which 10
declines first in urban areas, among
5
more educated women, and among
wealthier households. As family plan- 0
Lowest quintile Highest quintile
ning programs and other providers
are at first not able to fill the increased Bangladesh 2007 Egypt, Arab Rep. 2005 Togo 2006
demand for contraceptives or ad- Benin 2001 Ghana 2003 Uganda 200�01
Bolivia 2003 Kyrgyz republic 2005�06 Zimbabwe 2005�06
dress concerns about health and side
Chad 2004 Mali 2006
effects, unmet need increases in the Central African Republic Nigeria 2003
wealthier quintiles, while it remains 1994�95
low in the poorest quintiles where
demand for family planning remains Source: Demographic and Health Surveys, Multiple Indicator Cluster Surveys.
low. Over time, contraceptive use in-
creases among the wealthier quintiles
and met need reduces unmet need, at
which time the patterns reverse. At the
pre-transition and late transition phases of fertility response to a BCC programs instituted to influence
decline, unmet need may be uniformly low for all couples to desire smaller families could be interpret-
quintiles. ed as a success; subsequently, unmet need should
decrease with increasing access to quality family
planning services.
Trends in unmet need
As discussed above, the extent of unmet need for Summary and implications for
contraception in a given country changes over time
as desired family size and contraceptive use patterns
Bank operations
change, and does not necessarily decrease with
It is important not to interpret high levels of unmet
improved access to family planning services[3]. Thus,
need as the failure of a family planning program,
low levels of unmet need do not always in-
as unmet need is a dynamic indicator. It changes
dicate success of family planning programs
from low levels in countries in which fertility prefer-
and vice versa.
ences have not started to decline to higher levels
during the fertility transition period, and back to
Indeed, as shown in Figure 6, in the past two
low levels as the demand for small family size
decades unmet need for contraception increased
becomes fulfilled.
in Uganda, it decreased in Egypt, and in the case
of Ghana there was no appreciable change. In The existence of unmet need is sometimes inter-
Bangladesh contraceptive use increased from 45 preted as evidence of lack of access to a source
percent to 56 percent during 1993�2007. Dur- of contraceptive supplies due to supply constraints
ing this period, unmet need first decreased, then or to financial costs. However, there are many
increased. reasons why women do not use contraception
and family planning programs must do more than
In a country with high TFR but low unmet need supplying methods of contraception at affordable
such as Niger, an initial increase in unmet need in prices.
6
Figure 6. Trends in unmet need and CPR during 1990�2008, selected countries
Bangladesh Egypt
70 70
60 60
50 50
40 40
30 30
20 20
10 10
0 0
1990 1995 2000 2005 2010 1990 1995 2000 2005 2010
CPR Unmet need CPR Unmet need
Ghana Uganda
70 70
60 60
50 50
40 40
30 30
20 20
10 10
0 0
1990 1995 2000 2005 2010 1990 1995 2000 2005 2010
CPR Unmet need CPR Unmet need
Source: Demographic and Health Surveys
In monitoring and evaluation of family plan- In the design of projects which aim at improving
ning programs, an increase in unmet need or no access to and quality of family planning pro-
change in unmet need does not always imply that grams, it is important to understand the reasons
the intervention was not successful. One needs to why women are not using contraceptives. Infor-
take into account other indicators such as CPR, mation on the reasons for not intending to use
TFR, fertility preferences, method mix, and reasons contraceptives is available in the DHS and other
for not using contraceptives. surveys.
7
References
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and Implications for Population Policy Population and Development Review 26: 4 691�723.
2. Westoff, C F. 2006. New Estimates of Unmet Need and the Demand for Family Planning. DHS Com-
parative Reports No. 14. Calverton, Maryland, USA. Macro International Inc. Available on the Web
at http://www.measuredhs.com/pubs/pdf/CR14/CR14.pdf. Access February 22, 2010.
3. Robey, 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, Sep-
tember 1996. Available on the Web at http://www.infoforhealth.org/pr/online.shtml. Accessed Febru-
ary 22, 2010.
4. Westoff, CF. and Bankole, A. Unmet need: 1990�1994. Calverton, Maryland, Macro International,
Jun. 1995. (DHS Comparative Studies No. 16) 55 p.
5. Westoff, CF. and Ochoa, LH. Unmet need and the demand for family planning. Columbia, Mary-
land, Institute for Resource Development. Macro International, Jun. 1991. (Demographic and Health
Surveys Comparative Studies No. 5) 43 p.
6. Westoff, CF. The unmet need for birth control in five Asian countries. International Family Planning
Perspectives 10(3): 173�181. May�Jun. 1978.
8