Unmet Need

The gap between preferences and actual fertility springs from what demographers label the "unmet need for contraception." Through survey questions that identify women who would prefer to delay or terminate childbearing but who are not using contraception despite the risk of pregnancy,¹⁶ demographers estimate that unmet need affects 10 to 40 percent of married women of reproductive age in developing countries. Levels of unmet need (Table 1) are high in high-fertility countries, such as Malawi (36 percent), but are still substantial in relatively advanced regions, such as Latin America, where they range from 12 to 29 percent. For all developing countries, the total with unmet need is estimated at about 150 million women.¹⁷

¹⁶This excludes those assumed not to be at risk: (1) those protected by postpartum anovulation, the temporary infertility that follows a pregnancy, which can be extended by continued full breastfeeding; and (2) the infecund, identified by not having conceived in five years despite taking no preventive measures, by not having menstruated in six months, or by claiming they could not have a baby or were menopausal.

¹⁷According to unpublished tabulations of Demographic and Health Survey data by Shea Rutstein (1997, personal communication). Precise definitions and therefore estimates of unmet need do vary somewhat, but the total of the estimates in Table 1 - 75 million women with unmet need across only 44 developing countries - appears consistent with this.

Unmet need is essentially a conflict between what a woman wants and what she does about it: She wants lower fertility but fails to do what is needed to prevent pregnancy. The reasons couples want smaller families are numerous and generally well-founded, from the financial strain large numbers of children put on households to the strain of continual childbearing on a woman's health and energy. Preferences for small families inevitably increase as societies modernize: Financial pressures grow; the need to educate children becomes more apparent; and the desire for more creature comforts or at least for release from unremitting childbearing begins to seem possible as the media promote alternative lifestyles. At levels of fertility reported in some earlier national surveys (as in Kenya in the 1977-1978 period), women spent the equivalent of six continuous years of their lives pregnant and 23 years caring for children younger than six years old (World Bank, 1993a, p. 9). With the early childbearing typical in some countries, pregnancy can account for more than a quarter of female school dropouts, beginning as young as primary school.¹⁸ Controlling their fertility can give women options and a degree of freedom not previously available.

¹⁸ As in Cameroon, as reported by Eloundou-Enyegue (1997).

Table 1 Married Women of Reproductive Age with an Unmet Need for Contraception