by David Canning, Mahesh Karra
Studies in Family Planning, 27 January 2023 (Open access)
While there is a large literature on the prevalence of unmet need for family planning, there is no matching quantitative evidence on the prevalence of unwanted family planning; all contraceptive use is assumed to represent a “met need.” This lack of evidence raises concerns that some observed contraceptive use may be undesired and coercive. We provide estimates of unwanted family planning using Demographic and Health Survey data collected from 1,546,987 women in 56 low- and middle-income countries between 2011 and 2019. We estimate the prevalence of unwanted family planning, defined as the proportion of women who report wanting a child in the next nine months but who are using contraception. We find that 12.2 percent of women have an unmet need for family planning, while 2.1 percent have unwanted family planning, with estimated prevalence rates ranging from 0.4 percent in Gambia to 7.1 percent in Jordan. About half of unwanted family planning use can be attributed to condoms, withdrawal, and abstinence. Estimating the prevalence of unwanted family planning is difficult given current data collection efforts, which are not designed for this purpose. We recommend that future surveys probe the reasons for the use of family planning….
Conceptually, there are two possible violations of the rights-based approach to family planning and a lack of concordance between women’s desired and actual use of family planning: (1) women who want to use contraception may not be able to do so; and (2) women may be using contraception when they do not want to use a method. The unmet need for family planning can be thought of as a measure of one type of discordance, while our proposed measure of unwanted family planning can be thought of as a complementary indicator for the other type of discordance. Quantitatively, we find the unmet need for family planning to be, by far, the larger problem, given its significantly higher prevalence. However, the estimates for unwanted family planning, as measured by our proposed approach, are not zero and are surprisingly high in a number of countries.
The large-scale use of condoms, withdrawal, and periodic abstinence among unwanted family planning users, which are methods that involve male participation, is consistent with the idea that this contraceptive use may reflect men’s fertility preferences and their demand for contraception rather than women’s own preferences.… The widespread use of condoms by women with unwanted family planning is also consistent with a desire to protect against HIV and other sexually transmitted diseases, while the contraceptive effect from this use may be unwanted. This may be particularly relevant in the case of countries like South Africa, where the HIV prevalence rate is high and where condom use is encouraged to prevent the spread of HIV. While condom use may be desirable to prevent HIV, there may be a cost in the form of unwanted family planning among women who want to have a child soon, whereby the contraceptive effect of the condom may be unwanted.
Most worrying is the relatively large use of IUDs by women with unwanted family planning, particularly in Jordan, where it explains a large fraction of the high unwanted family planning rate. IUD use is a large part of the method mix in Jordan for women who defiantly want family planning. There are several qualitative studies finding that women in different settings have difficulty accessing removal services for long-acting contraception…. In addition, it would be necessary to examine the dynamics, and particularly the temporal lag, between a woman’s preference to not use contraception and her (in)ability to act on this preference. Understanding these dynamics would require a deeper exploration as to how method discontinuation may be related to unwanted use….
We recommend that future survey efforts and final reports present disaggregated statistics of contraceptive use by wantedness rather than defining all contraceptive users as having a “met need.” We also recommend that women who are using contraception and who want to have a birth within the next nine months, which is currently reported as having a met need for spacing, be reported as having unwanted family planning in future analyses. In addition to our proposed changes to reporting, we recommend that the DHS and other reproductive health surveys take greater steps to probe the extent of concordance in fertility preferences and contraceptive use so that our measurement and understanding of unwanted, and potentially wanted, family planning can be improved. First, women who report being sterilized should be followed up to determine if they did so voluntarily and if their inability to have children indeed reflects their fertility preferences. No available DHS survey has elicited fertility preferences for sterilized women, and it is, therefore, not possible to calculate prevalence estimates of unwanted family planning for this subgroup; as a result, we are likely to be undercounting unwanted family planning. Second, when women who are using contraception report wanting to have a birth soon or within the next nine months, there should be a process for following up with them that identifies the reasons for their use. We have made some suggestions as to why these women may be using contraception, but it would be useful to conduct both qualitative and quantitative studies that identify the underlying motivations for contraceptive use among women who want to have a child within nine months. These studies should also probe women’s understanding of wanting a birth “soon” to ensure we are capturing the full range of reasons for their use. Quantifying the scale and qualifying the causes of this issue are a necessary first step in determining what policies and intervention strategies can be adopted by programs to rectify it.