Introduction
Unmet need for contraception is an essential metric for monitoring reproductive health policy and programming. It is also used as a building block for estimating the proportion of women whose need for family planning is satisfied by modern methods, an indicator (3.7.1) to measure progress towards the Sustainable Development Goal number 3.1 2 A primary goal for meeting women’s or couples’ need for contraception is to prevent unintentional pregnancies, which directly affect maternal morbidity and mortality.3 A series of studies has shown substantial progress towards reducing the global proportion of women with unmet need in the last two decades.4 5 Such reductions by the use of contraception are estimated to have averted 38 maternal deaths for every 100 000 women of reproductive age in 2008.6 Projections indicate that complete elimination of global unmet need comprising an estimated 214 million women in 2017 would prevent another 29% of maternal deaths.7
Projections of contraceptive unmet need, however, are clouded with uncertainty due to conceptual and methodological weaknesses in measurement. Peterson and colleagues reported a 14% point difference in two global estimates of unmet need,8 evaluated at 26% of women of reproductive age by Darroch and Singh5 and 12% by Alkema and colleagues.4 These differences contribute to substantial variation in estimates of the number of women with unmet need, ranging from 134 million to 222 million, which draws attention to the different specifications of the measure.8
While the concept is simple: non-use of contraception among women who could become pregnant without wanting to do so, the construct is complex as the standard measure of unmet need does not represent a point prevalence.9 10 Specifically, the definition considers some women who are not currently at risk of becoming pregnant as having an unmet need for contraception. These include pregnant women whose pregnancy was unintended as well as some women who have had no sexual activity for an extended period of time. This latter concern is reflected in studies reporting that the most common reason for unmet need is that women indicate they do not need contraception because they are not sexually active.11 As shown by Bradley and Casterline, the exclusion of these women substantially reduces the estimate of unmet need.10 In the other direction, a few women who may have an unmet need are not captured in the standard definition. This is the case of postpartum amenorrhoeic women who will ovulate before their menses return, especially if they are not breastfeeding.12 In the existing definition, postpartum amenorrhoeic women are classified as having no need for contraception in the 24 months postdelivery unless their last birth was unintended.13 Various authors have challenged this classification,14 arguing that all women in the postpartum period have a need for contraception, regardless of pregnancy risk15 or that postpartum women have a need for contraception unless they are otherwise protected by postpartum abstinence or practicing the lactation amenorrhoea method (LAM).16 Comparing a 6-month with a 24-month postpartum cut-off, Bradley and Casterline noted that the standard unmet need algorithm is ‘highly sensitive to the choice of duration of postpartum amenorrhoea’.10 Using a current status (CS) measure of unmet need over the full 24 months postpartum period, which accounts for LAM and abstinence, Rossier and colleagues found lower estimates of unmet need than the standard retrospective measure (27% vs 32%).14 Further restrictions to sexually active and non-amenorrhoeic postpartum women, yield even lower estimates.17
In addition to its deviation from a point prevalence measure, the most important critique of the standard measure of unmet need is its inability to distinguish fertility intentions from contraceptive motivations.9 The assumption underlying the construct is that exposure to unintended pregnancy due to contraceptive non-use equates to an unfulfilled demand for contraception that can be addressed by improving knowledge and access. This assumption fails to recognise that contraceptive motivation may not align with fertility intentions. A number of demographers have formalised the distinction by differentiating readiness to use contraception from willingness to use, although they generally refer to willingness as attitudes towards contraception rather than intentions to use.18 19 The few studies assessing contraceptive intentions show that a sizeable proportion of women classified as having unmet need indicate that they have no intention of using contraception in the future20 and while little attention has been given to contraceptive intentions as opposed to pregnancy intentions, existing prospective studies suggest a high predictive value of contraceptive intentions on subsequent use.21 22 For instance, using Demographic and Health Survey (DHS) panel data from Morocco, Curtis and Westoff showed that 76% of women who intended to use contraception within the next 12 months reported subsequent use, versus 30% of women who did not intend future use.22 This transition from intention to use can be understood using Prochaska and DiClemente’s transtheoretical model of change, which posits that behavioural change occurs through different stages, moving from precontemplation, to contemplation and preparation, to action and maintenance.23
Building on previous research exploring departures of the standard demographic unmet need indicator from a point prevalence estimator,10 17 the current study seeks to comprehensively address some of these methodological challenges by proposing a new point prevalence measure of unmet need for contraception (CS unmet need) and by developing a point prevalent measure of unmet demand for contraception (CS unmet demand). CS unmet need aims to identify non-contraceptive users who are at risk of unintended pregnancy at the time of the survey. CS unmet demand is intended to distinguish women at risk who are ‘interested but unwilling’ to use contraception from those who are ‘interested and willing’.