Unmet Need

The Value of Family Planning Programs in Developing Countries (RAND, 1998, 98 p.)

Chapter Two - THE NEED FOR FAMILY PLANNING

Desire for Smaller Families

		(introduction...)
		Unmet Need
		Reasons for Unmet Need

(introduction...)

These potential benefits, however substantial they could appear to government planners, may not be the most important argument for seeking lower fertility. More significant is the fact that millions of couples in developing countries actually want to have smaller families. Motivated not by macroeconomic considerations but by practical concerns about family finances, health and well-being, and the future of their offspring, millions around the world would prefer to have fewer children than they are actually having.

Figure 10 compares the number of children women wanted, on average, in the early 1990s with total fertility across 28 developing countries in the 1990-1995 period. These countries are arrayed from those with the highest to those with the lowest desired family size. Except where desired family size exceeds six children (a setting somewhat overrepresented in this figure because more than half the data are from sub-Saharan Africa), the actual number of children tends to exceed the number desired by about three-fourths of a child on average.¹⁵

¹⁵Looking at number wanted person by person, one can identify births that exceed each person's desired number. Such calculations indicate even more "unwanted" births than suggested by Figure 10 (Bankole and Westoff 1995:24-25).

Figure 10 - Number of Children Desired and Total Fertitlity in 28 Countries

NOTE: Where available, desired family size is for all women; otherwise, it is for women ever married (Bankole and Westoff, 1995).

These statistics refer to what women - mostly married women - want. But men tend to have fairly similar, only slightly higher, preferences, except in the highest-fertility settings. Again excepting countries where average desired family size exceeds six children, men's preferred family size is usually higher than women's by no more that 0.1 or 0.2 children (Ezeh et al., 1996, p. 29) and therefore is still most often below actual fertility.

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.

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

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

Country		Survey Year	Percent	Number (1000s)
Africa
	Botswana	1988	27	27
	Burkina Faso	1992-1993	33	522
	Burundi	1987	25	201
	Cameroon	1991	22	347
	Ghana	1994	33	759
	Kenya	1993	36	1,101
	Liberia	1986	33	131
	Madagascar	1992	32	551
	Malawi	1992	36	498
	Mali	1987	23	435
	Namibia	1992	22	22
	Niger	1992	19	243
	Nigeria	1990	22	3,928
	Rwanda	1992	37	332
	Senegal	1992-1993	29	350
	Sudan	1989-1990	25	940
	Tanzania	1991-1992	27	1,065
	Uganda	1988-1989	27	707
	Zambia	1992	31	368
	Zimbabwe	1994	15	207
Asia
	Bangladesh	1994	18	3,852
	India	1992	20	31,005
	Indonesia	1991	14	4,427
	Nepal	1991	28	970
	Pakistan	1991-1992	32	5,738
	Philippines	1993	26	2,512
	Sri Lanka	1987	12	332
	Thailand	1987	11	999
Latin America and the Caribbean
	Bolivia	1994	24	235
	Brazil	1986	13	3,034
	Colombia	1990	12	545
	Dominican Rep.	1991	17	171
	Ecuador	1987	24	411
	El Salvador	1985	26	182
	Guatemala	1987	29	382
	Mexico	1987	24	3,133

	Paraguay	1990	15	395
	Peru	1991-1992	16	471
	Trinidad/Tobago	1987	16	32
Middle East Crescent
	Egypt	1992	22	1,818
	Jordan	1990	22	110
	Morocco	1992	20	650
	Tunisia	1988	20	217
	Turkey	1992	11	1,062

Source: Robey et al. (1996).

Lower fertility preferences are translated into lower fertility in the long run. Over many years, successive cohorts reduce their fertility to modern low levels in the course of socioeconomic development. But this process is lengthy and not automatic: It took a century in industrial countries and several decades in such countries as South Korea and Thailand. In the process, many couples must cope with larger families than they want and with poorly timed births.

Reasons for Unmet Need

The reasons for this delay are discernible in the obstacles women cite to contraception when they otherwise have good reason to use it. These obstacles are shown in Figure 11, which tabulates the principal reasons respondents give in surveys taken in 13 countries for not using contraception when they want to avoid a birth (Bongaarts and Bruce, 1995). These reasons are grouped for convenience into four categories: poor access, concerns about using contraception, objections to family planning, and other reasons. The most important single reason is lack of knowledge about contraception, its use, or its availability, cited by one-quarter of those with unmet need. The second most important is concern about the health effects of contraception, cited by one-fifth.

Neither obstacle is something most women in developing countries can overcome without help, and poorly educated and impoverished women should not need to rely entirely on the altruism of pharmaceutical firms or private doctors for education about contraception and provision of safe and appropriate methods. Contraception is in fact quite safe. What health risks some methods carry are small relative to the risks of a typical pregnancy. It is estimated that the mortality risk of an unplanned, unwanted pregnancy is 20 times the risk of any modern contraceptive method and 10 times the risk of a properly performed abortion (Ross and Frankenberg, 1993, p. 86). Still, misuse of contraceptives is possible and needs to be minimized by promoting wide knowledge of contraception and ensuring safe and effective services.

Figure 11 - Why Women Do Not Use Contraception Despite Wanting to Avoid a Birth (percent)

NOTE: "Sources limited" is referred to as "lack of access/difficult to get" in the original study (Bongaarts and Bruce, 1995).

Family planning programs - organized efforts to provide contraception and provide associated reproductive health services - address the two main obstacles to contraceptive use, as well as various others, such as limits on the supply of contraceptives and their cost. The cost, to impoverished couples, can be substantial: The retail price of an annual supply of contraceptive pills exceeds US$l00 in half a dozen developing countries, as does the retail price of an annual supply of condoms. Costs that reach 5 percent of average household income are common, and costs reach 20 percent of income in some sub-Saharan countries (World Bank, 1993a, pp. 33-34). Inadequate supply and high cost are each cited as the main obstacle to contraception by 3-4 percent of women, but these low figures may be misleading. For instance, someone with poor knowledge about contraceptives is unlikely to complain about supply or cost (Ross, 1995). The low salience of these reasons may also reflect program successes in supplying cheap contraceptives at the same time they raise awareness. The proportion of women with an unmet need for contraception who cite lack of knowledge as the main obstacle is sharply lower in countries where education programs are more active. The proportion citing health concerns, on the other hand, is not reduced but rises, suggesting one of the continuing challenges to such programs.¹⁹

¹⁹The correlation across 13 countries between family planning effort in 1989 and the proportion of those with unmet need citing lack of knowledge is -0.81. Using the proportion of all women rather than just those with unmet need, the correlation is -0.73. Similar correlations, for health concerns, are 0.52 and 0.09. Thus, women with health concerns increase with family planning effort as a proportion of those with unmet need, though not as a proportion of all women.

The other reasons for unmet need are more problematic. Objections to family planning that the woman or others who influence her may have are fairly important, but exactly what these objections are is not clear from the survey evidence. A husband may disapprove, for instance, because he wants more children or because he is concerned about health effects, bothered by the inconvenience, or distrustful of traditional methods.²⁰Such objections may therefore also reflect informational or access issues or health concerns. Except for a woman's personal opposition to contraception, the objections also appear to be less prominent where programs are active.

²⁰An intensive study in the Philippines confirms the importance of husband's objections but does not reveal the reasons behind them (Casterline, Perez, and Biddlecom, 1997, pp. 183-184).

Family planning programs therefore appear capable of addressing the main obstacles to contraceptive use, potentially helping couples attain their desired family size and, in theory, providing societies with the demographic bonus that comes from reducing fertility. What such programs have actually contributed requires some examination.