Meeting unmet need: new strategies

This issue of "Population Reports" explores the concept of "unmet need" for family planning (FP) and presents new strategies FP programs can use to meet this need. To focus on unmet need, FP programs solicit the statements of women through surveys, identify the groups most likely to be interested in accepting contraception, and attempt to reach these groups with services. Unmet need affects over 100 million women in developing countries (a third of them in India) and an average of 20% of all married women of reproductive age in the developing world. Strategies to address unmet need should 1) maximize access to good quality services, 2) emphasize communication, 3) focus on men as well as women, and 4) collaborate with other services for new mothers and young children. This report opens with an introductory summary and then focuses on the relationship of unmet need and FP programs through a consideration of the concept and measurement of unmet need, the extent of unmet need, trends in unmet need, abortion as an indicator of unmet need, and unmet need versus demand for contraception. The second major section addresses the reasons for unmet need (which include health concerns and side effects, lack of information, family and community opposition, a perception that there is little risk of pregnancy, and apparent ambivalence). The third section considers who has unmet need and discusses unmet need levels by women's characteristics as well as differences among women with unmet need. The next section details the program implications and strategies mentioned above. Finally, a process to address unmet need is presented that depends upon analysis, strategic design, implementation, and monitoring/evaluation. Among the highlighted information is a checklist of possible programmatic steps to address the most common reasons for unmet need.     

Covert contraceptive use: prevalence, motivations, and consequences

This article examines women's covert use of contraceptives, that is, their use of a method without their husbands' knowledge. Three questions are addressed: (1) How is covert use measured? (2) How prevalent is it? and (3) What are the factors underlying covert use? Existing studies are used together with survey and qualitative data collected in 1997 in an urban setting in Zambia from married women and their husbands. Women's covert use of contraceptives is estimated to account for 6 to 20 percent of all current contraceptive use, and it is more widespread when contraceptive prevalence is low. The multivariate analysis indicates that difficult spousal communication about contraception is the strongest determinant of covert use. Husbands' disapproval of contraception works through spousal communication rather than as a direct influence on covert use. Husbands' pronatalism had no significant effect. The article concludes with implications of covert use for reproductive health and family planning programs, especially women's (and men's) needs for confidential services.     

Uptake of contraception during postpartum amenorrhoea: understandings and preferences of poor, urban women in Bangladesh

In urban Bangladesh, as in many other settings, an immediate postpartum family planning strategy prevails, where providers seek to promote and provide contraception at 40-45 days following birth to women regardless of their breastfeeding or menstrual status. Despite such practices, the majority of women choose to delay the initiation of contraception until menses resumes, often several months after birth. The present paper seeks to explain this discrepancy by describing poor, urban women's understandings regarding the chances of conception and the risks associated with contraceptive use in the postpartum period. Findings from in-depth interviews reveal that the majority of women perceive no personal risk of pregnancy during amenorrhoea, though most do not recognise an association between this diminished risk of conception and breastfeeding. In addition, the data illustrate that women are primarily concerned with their own and their newly born child's health and well-being in the period following childbirth, both of which are perceived to be extremely vulnerable. These perceptions, plus an understanding that modern methods of contraception are "strong" and potentially damaging to the health, mean that the majority of women are reluctant to adopt family planning methods soon after birth, particularly during postpartum amenorrhoea. The paper advocates that, since breastfeeding affords good protection against pregnancy for six to nine months following birth, efforts should be made to actively incorporate lactational amenorrhoea into postpartum family planning strategies in Bangladesh. Recommendations are also made for ways in which women may be encouraged to adopt contraception during amenorrhoea beyond the period of high natural protection. The paper highlights the importance of taking the client's perspective into consideration in attempts to improve the quality and effectiveness of family planning programmes.     

The long-term demographic role of community-based family planning in rural Bangladesh

Experimental studies demonstrating the effectiveness of nonclinical distribution of contraceptives are typically conducted in settings where contraceptive use is low and unmet need is extensive. Determining the long-term role of active outreach programs after initial demand is met represents an increasingly important policy issue in Asia, where contraceptive prevalence is high and fixed service points are conveniently available. This article examines the long-term rationale for household family planning in Bangladesh-where growing use of contraceptives, rapid fertility decline, and normative change in reproductive preferences are in progress, bringing into question the rationale for large-scale deployment of paid outreach workers. Longitudinal data are analyzed that record outreach encounters and contraceptive use dynamics in a large rural population. Findings demonstrate that outreach has a continuing impact on program effectiveness, even after a decade of household visitation. The policy implications of this finding are reviewed.     

Diffuse alveolar hemorrhage and systemic lupus erythematosus. Clinical presentation, histology, survival, and outcome

This article introduces the concept of men's unmet need for family planning and explains its programmatic relevance. Using data from Demographic and Health Surveys (DHS) of Ghana (1988, 1993) and Kenya (1989, 1993), married men are found to have high levels of unmet need for family planning that are comparable to, although slightly lower than, those for women. The importance of men's unmet need is demonstrated when the analysis is restricted to marital pairs in the DHS samples; trends in the joint unmet need of husbands and wives are shown to be closely associated with the nature of the fertility transitions occurring in Ghana and Kenya. Because of wide discrepancies found between husbands' and wives' unmet need statuses, family planning programs that foster spousal communication are likely to facilitate the transition to lower fertility.     

Socioeconomic development, status of women, family planning, and fertility in Bangladesh: a district level analysis

In this paper we examine the effects of socioeconomic development, the status of women, and family planning on fertility and the extent to which these effects vary among the nineteen districts of Bangladesh. The 1983 and 1991 Bangladesh Contraceptive Prevalence Survey data are used to examine the effects of these factors on differences in contraceptive use among currently married women aged 15-49. The proportion of currently married women aged 15-49 using contraception was 46.3 per cent in 1991, a considerable increase from 26.5 per cent in 1983. Contraceptive use rates for all the districts increased substantially over the period between 1983 and 1991 and the gap between Dhaka's rate and those of other districts was narrower in 1991 than in 1983. An analytical model composed of socioeconomic development, status of women, and family planning variables is tested using logistic regression. The logit model is used to evaluate the effects of a selected group of variables on the probability of using contraceptive methods. The analysis demonstrates clearly that socioeconomic development and women's status significantly impact the use of contraceptive methods in Bangladesh. The results also suggest that better-educated, employed women are more likely to use contraception than those who have little or no formal education and who are not employed. In 1983, rural-urban differences in contraceptive use were significant, but in 1991 area of residence was not significant, which suggests that family planning programs may have played an important role in providing contraceptive information and technology to rural areas. Our analysis also suggests that family planning programs operated more efficiently in some districts than in others, and regional differences remained important in 1991 as they were in 1983. Decomposition analysis suggests that shifts in population structure favored increased contraceptive use in Bangladesh. This analysis also indicates that change in rate is also important, contributing about 21 per cent of the overall increase in contraceptive use.     

Update on contraception

Genitourinary medicine (GUM) clinics are likely to play an expanded role in the provision of family planning services. A recent survey of GUM clinics in the UK indicated that 71.4% provided emergency contraception and 48.1% provided routine contraception services. To facilitate the ability of GUM practitioners to provide contraceptive counseling and supplies to both men and women, this article reviews the current state of emergency contraception, combined oral contraceptives (OCs), modern IUDs, the levonorgestrel-releasing intrauterine system, female condoms, and the personalized computerized contraceptive system Persona. Also reviewed are current issues regarding the possible impact of combined OCs on an increased risk of venous thromboembolism and breast cancer.     

Hepatitis C--role of perinatal transmission

Increasing family planning acceptance and efficacy is considered a key public health issue in many Pacific island nations. To assess the structure of family planning acceptance in Samoa, structured interviews were conducted with 155 reproductive age women from seven villages in both rural and urban settings. The survey data show accord with returns on contraceptive use from Samoan clinics, and demonstrate that awareness and use of contraception have increased markedly in the previous decade but desired family size remains high in younger women. A notable feature of the Samoan women's contraceptive experience is the lack of diversity of reported contraceptive behaviours and attitudes based on age, urban versus rural residence, and education.     

The role of the Family Planning Association in Hong Kong's fertility decline

The fertility decline in Hong Kong appears to be the result of 1) the economic and social development achieved during the 1960s which created an environment favorable to the development of a family planning program, and 2) the changes in the practice of and to a lesser extent the attitude toward contraception induced by the Family Planning Association (FPA). The FPA has motivated people to accept family planning services and has provided them with an inexpensive and convenient source of contraceptives. Prior to 1966, posters, pamphlets, and newspaper advertisements were the main sources of publicity with radio and television used only on a limited basis. Since 1966 the existing channels of communication have been modified and new approaches in the form of film showings, contests, and telephone inquiry services have been developed to inform and motivate couples to begin contraceptive practice. After many years of these publicity campaigns, over 95% of all married women in Hong Kong understand that contraceptives can be used for limiting births and practically all of them are familiar with the FPA. Additionally, the most important referral source, accounting for over 85% of all new acceptors, has been the person-to-person contact made by the FPA family planning workers as well as satisfied clients. In 1966 fieldwork operations were expanded and a new recruitment strategy was initiated in which activities were increasingly concentrated in maternal and child health centers. The effect of reaching young and low parity women in the mid- to late 1960s has been cumulative. Since 1969 there have been indications that fertility decline is increasing in the older age groups. Although the extent to which the FPA's activities encouraging the use of the more modern methods of contraception affected the fertility decline is difficult to determine, it is obvious that the population was receptive to the new and improved methods as evidenced by the boom of acceptors in 1965 when IUD insertions were at their peak and by the 2nd boom in 1969 when the large-scale distribution of orgal contraceptives began.     

Haiti: unions, fertility and the quest for survival

This essay examines Haitian cultural and programmatic barriers to modern contraception and reports on types of unions as they relate to pregnancy and the prevalence of contraception. Findings from three mini-surveys representing 2383 rural and urban women in unions show that the most popular unions are maryé and plasé (legal marriage and setting up an household). Among rural women living in unstable relationships, vivav'ek, remen and menaj (living with someone, lovers, living as a pair), about 18% reported being pregnant at the time of the surveys. Findings also reveal that more urban women use contraceptive methods (23%) than do rural women (13%). However, the choice of contraceptive method appears to be influenced by medical staff and the availability of methods. Discussion examines the results of the surveys, women's position within the culture and attitudes toward the use of modern contraception. It also gives suggestions for improving family planning services by reinforcing the training of providers and supplementing their work with a team of volunteers who would encourage and support first-time users and dissatisfied users with meetings and home visits. It is also suggested that the promotion of informal education and the teaching of practical skills in mothers' clubs would encourage women to become economically independent from their partners so they would not focus on reproduction as a means to tie a man to them for emotional and economic purposes.     

Why gender is a barrier to contraception advice

In the UK, the Contraceptive Education Service is attempting to place contraception services on the health care agenda for all health providers dealing with heterosexual and bisexual men. Contraceptive education can prompt men to take more responsibility for contraception. Recent surveys indicate that the taking of sexual histories varies not only from clinic to clinic but also among various practitioners working in the same clinic. An observational study revealed that contraceptive information was not displayed in a third of general practitioners' offices and 10% of family planning and sexual health clinics. While good reasons may exist for keeping the information under the counter, clients have expressed a desire for printed information that they can take home to read. Sexual health clinics (formerly called "genito-urinary" clinics) are being targeted as one of the best places to reach sexually active men. Currently inequalities exist between what female and male patients are asked. For example, men are not asked how many unwanted pregnancies they have caused. Nurses have a special role in health education because they are perceived to be more approachable than physicians. While nurses discuss condom use whenever they have the opportunity, most feel that schools are the best place for sexual health education. The nurses also felt that, whereas most men have no need for information about oral contraceptive usage, information on emergency contraception may prove valuable. One clinic is using new forms to take sexual histories and prompt providers to cover topics such as safer sex and risk reduction.     

Intrauterine devices: learning from the past and looking to the future

This paper reviews the historical development of the IUD, describing the challenges and successes, and attempts to offer a balanced perspective for family planning service workers today. Modern IUDs are an important component of family planning services and an excellent contraceptive choice for properly screened women, providing contraception that is safe, effective, long lasting and cost effective. Potential research strategies for the future are also discussed.     

Unplanned pregnancies in Harare, Zimbabwe: what is the contraceptive history and awareness of the mothers?

OBJECTIVES: The study aimed to estimate the proportion of unplanned pregnancies among mothers delivering at the referral Harare Hospital and to describe their levels of contraceptive use and awareness in relation to the planning of pregnancy. DESIGN: Systematic sample of mothers who had just delivered identified through maternity delivery, records. The study was analysed as a case-referent study where cases where mothers who had unintended pregnancies and those with intended or planned pregnancies served as referents. SETTING: Postnatal wards of Harare Maternity Hospital. SUBJECTS: 923 mothers following delivery. MAIN OUTCOME MEASURES: Socio-demographic characteristics, pregnancy planning, contraceptive history and contraceptive knowledge. RESULTS: Of the 923 deliveries studied, 377 (41%) were unintended (cases), of which 9% were unwanted. Mothers aged 19 years or below (Odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.6 to 3.7) and those aged 35 years or above (OR = 3.2, 95% CI = 1.8 to 5.5) were significantly more likely to report the index pregnancy as having been unintended. Nulliparous (OR = 2.4) and parity five or more (OR = 8.2) mothers were at significantly increased risk of unintended pregnancy. Mothers presenting with unintended pregnancies were also significantly more likely to be single (OR = 7.8), divorced/separated or widowed (OR = 6.0). Contraceptive ever use was 53% and 58% in cases and referents, respectively. The combined oral contraceptive pill was the most commonly known and used method of contraception. Contraceptive failure was reported by 23% of mothers with unplanned pregnancies. Previous use of the progesterone only pill (OR = 2.2), the condom (OR = 2.3) or the IUCD (OR = 6.3) were significantly associated with the likelihood of reporting with unplanned pregnancy. Mothers in both groups were concerned about contraceptive method failure, irregular menstruation and perceived subsequent infertility with contraception. Failure to discuss family planning with the male partner (OR = 2.3) or partner refusing use of contraception (OR = 2.8) constituted risk factors for unplanned pregnancy. CONCLUSION: Results point to the need for wider contraceptive counselling and provisions which encourage and involve the male partner. Programmes for reproductive health services and education should target women in identified high risk circumstances.     

The history of family planning among women who opt for surgical sterilization in the Social Security Fund of Panama

In this study, the previous history of family planning and prior usage of contraceptive methods are analyzed, in a sample of 175 women who voluntarily opted for surgical sterilization as a permanent method of fertility regulation, in the Panamanian Social Security System. A questionnaire was applied during the second trimester of pregnancy, by which information would be gathered in regard to knowledge, usage and adverse effects of the contraceptive methods used prior to the intervention. Results showed that 99% of the sample had heard, on some occasion about oral contraceptives (OC) and, in lesser proportion to intrauterine devices (IUD), barrier methods and hormonal inyectables. The first contraceptive method used, and the one of longest usage, was the combined OC, of which 43% begun between 17 and 25 years of age. In contrast, 7.4% initiated contraception with IUD, from the age of 26 years. The health personnel constituted the major source of recommendation for contraceptive usage and, despite the fact that 37% of the sample did not use contraception prior to the last pregnancy, over half of the subjects responded that combined OC were considered as the most secure method.     

Family planning program effects on the fertility of low-income U.S. women

Under rigorous statistical controls, it has been shown that the larger the proportion of lower SES women enrolled in organized family planning programs, the lower their fertility. Program effects independent of other social, economic and cultural factors were shown for lower SES whites and blacks, and for most age groups. The potential of a fully implemented program to reduce fertility differentials between upper and lower SES groups was assessed, using 1969-1970 fertility rates and the estimates of 1969 program impact. Although we believe that the program's impact has increased in magnitude over time, even these estimates from an early point in U.S. program development provide impressive documentation that the program reduces fertility in the subpopulation served by the program, and, by implication, that there is a genuine need for organized family planning services, even in an industrialized nation like the United States. If there were no need, there could be no program effect. The family planning program was one of the major new health and social programs introduced in the mid-1960s. This study shows that, far from failing, the program was succeeding very well in attaining its objectives. The program works because it gives women of lower socioeconomic status access to modern and effective methods of contraception that they would not otherwise have. As a result, the rates of unwanted and mistimed pregnancy of patients are lower than those of comparable women who lack access to organized clinic programs.     

Gender preference and birth spacing in Matlab, Bangladesh

Gender preference, particularly son preference, is believed to sustain high fertility in many Asian countries, but previous research shows unclear effects. We examine and compare gender-preference effects on fertility in two otherwise comparable populations in Bangladesh that differ markedly in their access to and use of contraception. We expect, and find, stronger effects of gender preference in the population that has more access to contraception and higher levels of contraceptive use. Thus gender preference may emerge as a significant barrier to further national family planning efforts in Bangladesh. We find that if a woman has at least one daughter, the risk of a subsequent birth is related negatively to the number of sons. Women with no daughters also experience a higher risk of having a subsequent birth; this finding suggests that there is also some preference for daughters. Son preference is strong in both the early and later stages of family formation, but women also want to have at least one daughter after having several sons.     

Hormonal male contraception: progress and prospects for the 21st century

During the second half of the 20th century, progress in developing novel, practical contraceptive methods for men has lagged significantly behind developments for women. Despite the lack of reliable, reversible methods, men throughout the world continue to be strongly involved in family planning but a greater involvement will require more attractive and reliable contraceptive options for men. The closest to fruition are hormonal methods the features of which are reviewed. Landmark WHO contraceptive efficacy studies have established that hormonally-induced azoospermia provides highly effective and reversible contraception for at least 12 months with minimal short-term side effects. Even among the small subgroup of men who remain oligozoospermic during hormonal suppression, good contraceptive efficacy is achieved. The present goals are to develop improved second generation hormonal regimens which provide more uniform azoospermia to obviate the need for monitoring of sperm output and to develop long-acting depot testosterone formulations used alone or with additional gonadotrophin suppressive agents such as progestins or GnRH antagonists. Significant obstacles to progress are the flight of industry from contraceptive R&D dur to the financial deterrent posed by the product liability crisis as well as the low priority accorded male reproductive health. Together those will determine whether the range of contraceptive options available to our children in the 21st century will improve, or whether the historically recent unbalanced increase in reliance on women for family planning will continue.     

Sterilization in Finland: from eugenics to contraception

The purpose of this paper was to describe the transition of sterilization in Finland from an eugenic tool to a contraceptive. Historical data were drawn from earlier reports in Finnish. Numbers of and reasons for sterilizations since 1950 were collected from nationwide sterilization statistics. Prevalence, characteristics of sterilized women, and women's satisfaction with sterilizations were studied from a 1994 nationwide survey (74% response rate). Logistic regression was used for adjustments. In the first half of the 20th century, eugenic ideology had influence in Finland as in other parts of Europe, and the 1935 and 1950 sterilization laws had an eugenic spirit. Regardless of this, the numbers of eugenic sterilizations remained low, and in practice, family planning was the main reason for sterilization. Nonetheless, prior to 1970 not all sterilizations were freely chosen, because sterilizations were sometimes used as a precondition for abortion. Female sterilizations showed remarkable fluctuation over time. Male sterilizations have been rare. The reasons stipulated by the law did not explain the numbers of sterilizations. In a 1994 survey, 9% of Finnish women reported they were using sterilization as their current contraceptive method (n = 189). Compared to women using other contraceptive methods, sterilized women were older, had had more births and pregnancies, and came from lower social classes. Sterilized women were satisfied with their sterilization, but there were women (8.5%) who regretted it. In conclusion, sterilizations have been and are likely to continue to be an important family planning method in Finland. The extreme gender ratio suggests a need for promoting male sterilizations, and women's expressed regrets suggest consideration of a higher age limit.