Language and Measurement of Contraceptive Need and Making These Indicators More Meaningful for Measuring Fertility Intentions of Women and Girls

HISTORICAL PERSPECTIVE OF NEED-BASED MEASURES

Unmet need was originally referred to as the knowledge, attitudes, and practices (KAP) gap, or “KAP-gap,” taking its name from a suite of surveys fielded in the 1960s developed to capture KAPs of women to permit direct examination of birth rates, fertility desires, and contraceptive use behaviors. KAP surveys were followed by World Fertility Surveys (WFS) and then Demographic and Health Surveys (DHS).^†Across these country-based surveys, significant proportions of women married or living with a partner in union reported they desired to limit fertility and were not using contraception; this was referred to as the “KAP-gap.”⁵ The KAP-gap was later renamed “unmet need for family planning” by Westoff in analyses of WFS data from Asia.^6,7

The Programme of Action from the 1994 International Conference on Population and Development (ICPD) emphasized meeting the fertility desires of individual women and men, instead of achieving demographic targets.⁸ This move toward meeting women’s and couples’ reproductive intentions aligned well with the concept of “unmet need for family planning”—the percentage of women who have the intention to avoid pregnancy but are not using contraception to meet that intention.

The measurement of unmet need has been refined over time using DHS data to better measure the pool of women who are not using contraception who represent the potential demand for contraception, called “total unmet need.” The revised measure was meant to address identified problems with the KAP-gap by including spacing preferences and acknowledging that some women were pregnant or postpartum amenorrhoeic at the time of the survey resulting from a pregnancy that was mistimed or unwanted and that they likely had unmet need before they became pregnant.⁹ Additional refinements improved measurement of fecundability and included sexually active unmarried women (Box 1).^6,10,11

Women who are infecund or who are unmarried and have not had sex in the last 30 days are considered to have no need for contraception.¹² A major criticism of the measure has been that the unmet need definition does not include questions about whether women want or intend to use contraception.¹³

Over time, unmet need went from solely a demographic measure to a key indicator used to measure progress across global calls to action, including Millennium Development Goal 5b. The indicator later became key to UNFPA’s ICPD+25 transformational goal of zero unmet need and part of the FP2020 and now FP2030 indicators.

Additional indicators that relate to unmet need have been developed and are now part of global measurement agendas including total demand for contraception and demand satisfied (Box 1). Demand satisfied assesses the overall proportion of women who want to delay or avoid childbearing who are currently using contraception themselves or are relying on their partners’ method use.¹⁴ This measure is considered by some to reflect voluntarism and informed choice because it does not set contraceptive prevalence nor fertility targets but rather emphasizes the imperative to satisfy individuals’ and couples’ own choices regarding the number and timing of children.¹⁵ That said, demand satisfied, like unmet need, does not take into consideration whether women are freely choosing to use a method nor if they are using the method of their choice.¹⁶ Also, like unmet need, it assumes that all married women are exposed to the risk of pregnancy, which is demonstrably untrue and biases measures of need upward.¹⁷ Demand satisfied with modern methods is a key indicator for Sustainable Development Goal target 3.7 to ensure universal access to sexual and reproductive health care services by 2030.

CHALLENGES WITH LANGUAGE AND USE OF NEED-BASED MEASURES

While the measurement of unmet need, demand satisfied, and total demand has evolved and improved, the use of these measures has consistently been a challenge. Unmet need and demand satisfied have frequently been misinterpreted as reflections of women’s intentions—that women who are classified as having unmet need or demand want to use contraception. While this would appear to be a logical interpretation based on the terms "need” and “demand," unmet need does not actually measure a woman's individual preferences for contraception, only the gap between reported fertility preferences and current contraceptive use. In fact, while proportions vary widely by country, overall about half of the women who are classified as having unmet need based on their responses to survey questions about their fertility intentions and contraceptive use say in that same interview that they do not want nor intend to use contraception in the future.¹⁸ Further, many women have ambivalent fertility desires (i.e., are undecided about future childbearing or the timing of future childbearing).¹⁹ Such women may be misclassified as having an unmet need when indeed they have no desire or intention to use a method in the future and may welcome an “unexpected” pregnancy,^20–22 although the majority of women with unintended pregnancies obtain abortions.²³

As noted previously, problems with language that is currently used to describe need-related indicators are further illustrated through the label of “demand satisfied” for contraception and especially “demand satisfied for modern methods.” An individual’s preference may not be satisfied in the case where a woman may have limited method choices or where she is dissatisfied with the use requirements or side effects of her current method.^24,25 Further, demand typically reflects what a woman (or couple) wants and is willing to do. Thus, to assess demand satisfied, we would want to ask people more directly what they want, whether they have the agency/capability to realize this option, and what satisfaction means to them.²⁶

At an individual level, the seeming discrepancy between intentions and use can be understood as a woman’s personal cost-benefit analysis: she may want to avoid pregnancy, but that “benefit” of avoiding pregnancy may not be large or strong enough to outweigh the “costs” associated with contraceptive use or with use of specific methods. These “costs” may include those related to supply such as financial and/or time costs to access and obtain the method of her choice as well as those related to personal or social issues, such as experienced or feared side effects, potential partner or community opposition of contraception, and health concerns, among others.^27,28 From a reproductive justice perspective, based on established human rights,^29,30 the individual has the right to choose to use or not to use a contraceptive method to meet her fertility desires, and thus, her self-reported needs and wants must be assessed to better understand gaps in use, recognizing that some women may also be ambivalent toward pregnancy and/or contraceptive use.

Some girls and women, as well as people who do not identify as female, also use contraception for nonfertility-related reasons including menstrual control, acne prevention, or prevention of sexually transmitted infections, or may use methods for other noncontraceptive benefits. These people would be considered to have no unmet need for contraception based on their fertility intentions; however, as with other groups of users, they may not be using the method of their choice or may not be satisfied with their contraception.

As pointed out in their article that examines the history, use, and measurement of unmet need, Bradley and Casterline⁶ clarify that unmet need was never meant to indicate that the full population of women with an unmet need (e.g., 218 million women with an unmet need for modern methods in low- and middle-income countries as listed previously) lack access and would use a modern method if FP programs were made available. Unmet need and demand satisfied measures were meant to indicate what levels of contraceptive use and subsequent fertility rates would be achieved at the population level in a scenario where FP is universally available and accessible and all women wanting to avoid pregnancy chose to use contraception.

For program and policy makers, measures of unmet need have been used to identify potential gaps in service delivery and inequities in services. However, unmet need indicators do not solely or specifically reflect inadequacies in service delivery.¹³ Other measures are necessary to assess the local and personal contexts that affect women’s (and their partners’) interest and ability to use contraception.^6,31–33 In particular, unmet need measures fail to reflect whether women know about FP, whether they approve of it, if they intend to use it, and their ability to use it should they want to, that is, they fail to capture the numerous demand and supply-side factors that affect contraceptive use (Box 2).^34,35

Further, need-based measures are often used with reference specifically to modern contraceptive methods (e.g., the Sustainable Development Goal indicator of demand satisfied with modern methods and the FP2030 country indicators of unmet need for modern methods and demand satisfied with modern methods). Modern-method-focused indicators consider users of traditional methods to have an “unmet need” or not have their “demand satisfied.” It is important to make clear the implications of defining unmet need for modern methods versus unmet need for any method. A woman or couple’s use of traditional methods may reflect their choice and what is the most appropriate method for their current life phase and situation or it may reflect barriers to their use of a preferred modern method. If we examine these measures with a reproductive justice and human rights perspective,³ classifying women using traditional methods (and even nonusers) as “in-need” misses the consideration of whether traditional method use and nonuse is the person’s (couple’s) choice, a reflection of their agency or empowerment to choose a traditional method (or lack of agency or empowerment to choose a different method), or an indicator of difficulty being able to use their desired method. No matter a person’s fertility desires, they still have the right to choose not to use a method or to use a traditional method if that meets their self-identified preferences. Indeed, at the service level, understanding each individual’s desires and preferences and their life contexts is necessary to guide FP outreach and services to meet clients’ actual needs.

Measures of unmet need have also been used to illustrate funding requirements and potential impacts if all women (and their partners) who want to avoid pregnancy use a contraceptive method.^1,36 The estimates that result from this type of projection may overestimate service need since, as discussed previously, many women who are classified as having an unmet need may not want to use a method even if it is made freely accessible and available. They also overestimate service needs by assuming all women who are married or who had sex in the past 30 days are at risk of pregnancy if they do not report current contraceptive use.¹⁷ These estimates may also underestimate service need since some women and couples may be dissatisfied with their current method and if alternatives were offered, they might visit a facility to switch methods.²⁵ Given the possibility for over- or underestimation of unmet need and that demand satisfied fails to capture individuals’ actual preferences, these measures need to be reconsidered as the sole global indicators to measure progress toward universal access to FP and sexual and reproductive health services.

PROPOSED WAYS FORWARD

To look critically at our field and consider our approach to language and measurement in FP, we propose to consider measurement with a new lens. From a human rights and reproductive justice perspective, all people should have complete access to a full range of methods (operationally defined by the World Health Organization as at least 1 short-term, 1 long-term, 1 permanent, and 1 emergency method⁴) to use if or when they choose. However, even this definition may not meet everyone’s needs, particularly if they have preferences for specific short-term (i.e., pill over injection) or long-term (i.e., intrauterine device versus implant) methods; if they need or prefer to avoid hormonal methods; or if they need contraceptives that also prevent against sexually transmitted infections, for example. If geographic/physical, economic, administrative, cognitive, and psychosocial access³² are not maintained, gaps in use should not be interpreted as simply a mismatch between intentions and actions. The Sustainable Development Goals seek to advance universal access to sexual and reproductive health. If we were to achieve this goal, we could expect that all people who want to use contraception would have access to and the freedom to choose a method that meets their self-identified preferences—including a traditional method—as well as the freedom to choose not to use a method.

As we examine the next 10 years of global FP efforts under FP2030, now is the time to reconsider the measures and language we use to identify and support people to avoid unintended pregnancy in ways they prefer (Box 3). Notably, it is not that the indicators of unmet need, demand satisfied, and total demand must go away, but rather we can do 2 things: (1) change the language around these indicators to make their meaning clearer and more useful and potentially further refine their measurement; and (2) identify new, more salient indicators from the user perspective to pilot, validate, and hopefully use as we move global FP monitoring efforts forward.