3.2.08 Unmet Need and Method Mix: What they Tell us about Equity, Choice, and Program Priorities




Friday, November 15, 2013


Scott Radloff, The Bill & Melinda Gates Institute for Population and Reproductive Health
Roy Jacobstein, Engenderhealth
Jeff Spieler, USAID, Office of Population and Reproductive Health
Carolyn Curtis, USAID, Global Health/PRH/Service Delivery Improvement

Name of Preformed Panel / Nom du Panel préformé:

Unmet Need and Method Mix: What they tell us about equity, choice, and program priorities

Panel Overview / Description:

Panel Objectives
To increase participant understanding of:
- The latest worldwide, regional and national trends in contraceptive use, method mix, and unmet need for modern contraception, and their implications for equity, choice, and FP program priorities.
- The importance and feasibility of greater programmatic focus on the needs of delayers and limiters, given both the growing “youth bulge” and the increasing reproductive intention to limit, even in low-resource countries.
- The potential contribution improved and new contraceptive methods could make to expanding choice and reducing unmet need.
- Innovative program approaches that have increased postpartum and postabortion FP access and use in various low-resource countries, thereby meeting unmet need in underserved and often-vulnerable women and preventing unwanted and rapid repeat pregnancies.    

Panel Description
The panel consists of representatives from EngenderHealth, the Gates Institute, and USAID. Four interactive presentations will be given, based on the latest UN and DHS data on contraceptive use, method mix, and unmet need; secondary DHS analysis; review of published and program literature; review of contraceptive R&D literature; and individual and organizational experience.

Program and Policy Implications
Access to modern contraception has been widely accepted as an intrinsic good, a key health intervention and a human right. Increasing contraceptive use and reducing unmet need are critical for individual and community well-being and national development—and also a matter of equity and social justice. Sub-Saharan Africa and South Asia have the greatest need for increased resources for FP. South Asia has the highest unmet need, and sub-Saharan Africa has the highest proportion of unmet need, as well as highly circumscribed method choice and high lifetime risk of maternal mortality (1 in 31, compared with 1 in 4300 in high-resource regions). Inequities in method availability and FP access persist within countries as well. At times of highest need, certain categories of women—e.g., those who are poor, young, unmarried, postpartum, postabortion, or finished with childbearing—often lack access to a suitable choice of methods, if not to FP entirely. These should be high-priority categories for FP programs and services. Despite daunting resource constraints, some African countries, e.g., Ethiopia, Malawi, and Rwanda, have made FP a high program priority and achieved notable success, as reflected in improved access, equity, method choice, and modern method use. Other African countries should emulate this political will and resource commitment, while following their own distinct path to greater and more equitable FP service provision. 

Presentation 1 Title / Titre de la présentation 1:

The What-nots, Why-nots, and So-whats of Contraceptive Use, Method Mix and Unmet Need

Presenter of Presentation 1 / Auteur de la présentation 1:

Scott Radloff, the Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health

Presentation 1/ Présentation 1:

Contraceptive use has increased 18-fold in developing countries the last 50 years, from 31 million to 570 million women using a modern method. Despite this growth, substantial unmet need for FP remains. In addition, many women do not have easy access to a range of contraceptive methods, especially to more highly effective, long-acting reversible and permanent methods (LARCs/PMs). Hence, contraceptive use, method mix, and unmet need vary substantially across regions, sub-regions, and countries – as well as within countries, where rural, periurban and low-income women often have more limited access.

This presentation is based on secondary DHS analysis and the latest UN compilations of method mix and unmet need by country, sub-region and region. 

Results/Key Findings
Worldwide, modern contraceptive use (MCPR) is 56% among married women.  China and India alone account for half of worldwide use. Regional differences in MCPR are large, e.g., 67-73% in the Americas compared to 26% in Africa. Wide variations in MCPR exist within Africa as well: MCPR is 54% and 59% in Northern and Southern Africa, respectively – but just 8% and 11% in Middle and Western Africa, respectively.  There are also variations and inequities in access and use according to education, residence, income, marital status, and age.  Over 220 million women in low-resource countries have unmet need, including 83 million in South Asia and 53 million in sub-Saharan Africa, which has the highest proportion of unmet need (31%) of any region.  Female sterilization is the most widely-used method (19% CPR), and IUDs the most widely-used reversible method (14% CPR).  Access to LARCs/PMs is much lower in sub-Saharan Africa than in industrialized countries.  Fertility is falling in almost all low-resource countries.  Demand to limit now exceeds demand to space in many East and Southern African countries (as it does in other regions outside of Africa). In the least-developed countries unmet need is highest – for every woman using a modern method more than one has unmet need, and in some countries this ratio reaches 1:5.

Conclusions/Program & Policy Implications
Adopting approaches to reach women, especially those in rural and periurban areas, with a broader choice of methods can increase modern method use, reduce unmet need, increase satisfaction with method choice, and reduce discontinuation. Reaching women and providing services at key points in their life when their need is highest improves program responsiveness to needs. This includes reaching young women who want to delay first births and offering women who are post-partum and post-abortion a choice of spacing and limiting methods.

Presentation 2 Title / Titre de la présentation 2:

Start Too Soon, Stop Too Late: The importance of addressing the reproductive intentions of delayers and limiters

Presenter of Presentation 2 / Auteur de la présentation 2:

Roy Jacobstein, Engenderhealth

Presentation 2/ Présentation 2:

Family planning programs have made notable progress the past four decades. Modern method use has risen from negligible levels to 56%, fertility fallen from 4.7 to 2.6 lifetime births per woman, and maternal mortality declined. Progress lags in South Asia and Sub-Saharan Africa, however: Prevalence is lower, unmet need higher, and actual fertility exceeds wanted fertility. Young, sexually-active, never-married women—the cohort with high likelihood of wanting to delay a first birth—face greater difficulties than do married women in accessing contraception. Women postabortion or postpartum often do not receive FP. Because FP programs have difficulty providing highly effective clinical methods (LA/PMs) widely, reliably and equitably; limiters often must use short-acting resupply or traditional methods, which have much higher failure rates.

The presentation is based on UN Population Division data, secondary DHS analysis, literature review, recommendations of normative medical bodies, and individual and organizational experience.

Results/Key Findings
Sixty percent of the population in least-developed countries is aged 0–24. In many African countries almost half the population is under-15. One-quarter (26%) of all women in low-resource countries are unmarried, mostly adolescents or young adults; 44% of those who need contraception are not using a modern method. Unmet need among unmarried women in West and Middle Africa is 51%. WHO medical eligibility criteria indicate that young and nulliparous women can use implants without restriction, and can generally use IUDs. ACOG practice guidelines recommend that providers encourage these two methods as “the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women.” Their use is below 1-2% in almost all African countries, however, due to provider and program factors. Demand to limit is rising in African countries and now exceeds demand to space in Kenya, Madagascar, Malawi, Namibia, Rwanda, South Africa, and Swaziland. Still, LA/PM access and use is much lower in sub-Saharan African countries than in industrialized and advanced developing countries. Half of the 80 million annual unintended pregnancies in low-resource countries end in abortion. If all unmet need were met, over 100,000 maternal deaths would be prevented each year, mainly in South Asia and Sub-Saharan Africa.

Conclusions/Program and Policy Implications
Meeting clients’ reproductive intentions should be a primary strategy and goal of FP programs. Such client-centeredness should include an intensified focus on meeting needs of delayers and limiters, increasing access for young and unmarried women, and removing access barriers to LA/PM’s, including within contraceptive security efforts. This would improve many measures of method mix, equity, program quality, and women’s health and well-being.

Presentation 3 Title / Titre de la présentation 3:

At and Beyond the Horizon: New Technologies to Increase Choice and Address Unmet Need

Presenter of Presentation 3 / Auteur de la présentation 3:

Jeff Spieler, United States Agency for International Development

Presentation 3 / Présentation 3:

Recent reviews by the Bill & Melinda Gates Foundation, the  National Institutes of Health, USAID and the Institute of Medicine have called for renewed investment in contraceptive R&D on products that better address women’s and men’s reproductive interests, concerns, and life circumstances.  According to a May 2011 report by the Guttmacher Institute, 7 of every 10 women in Sub-Saharan Africa, South Central Asia and Southeast Asia who want to avoid pregnancy are not using modern contraceptives because currently available methods do not meet their needs.  The reasons women most frequently gave for not using contraception  include concerns about side effects (23%); infrequent sex (21%); being postpartum or breast-feeding (17%); and partner opposition (10%).  The Guttmacher Institute report further highlights the types of new methods that could increase contraceptive use and reduce unmet need, that have negligible side effects (to improve continuation), are appropriate for breast-feeding women, and could be used on demand by women with infrequent or irregular intercourse.

The presentation is based on extensive literature review and the speaker’s broad knowledge of what is new and in development in contraceptive technology, including information acquired in advisory committee and donor coordination meetings on contraceptive R&D, and discussions with researchers and companies.

There are two major approaches to investments in technology: 1)  Develop ‘adaptive technologies’ by improving existing methods to make them easier to deliver and use, less expensive, and/or more acceptable to potential users; and, 2) Develop totally new technologies that fill gaps not being met by existing or adaptive technologies.  Among relatively new adaptive technologies and totally new technologies to help better meet women’s FP needs are injectables, implants, hormonal IUDs, vaginal rings, female barrier methods, multi-purpose/dual protection methods and peri-coital methods.  Other new technologies to be developed that could have immediate application if shown to be safe, highly effective and low cost include non-surgical methods of male and female sterilization, and bio-degradable progestin implants.

Conclusions/Program and Policy Implications
Expanding contraceptive choice by making incremental improvements in existing methods and by developing totally new methods that fill important gaps in technology should result in greater access and choice; better fit with women’s and men’s circumstances; and less unmet need for delaying, spacing and limiting.  Ensuring that these methods will be made available to younger women and postpartum women, and as part of post-abortion care will further increase their utility.  Improved and totally new contraceptive methods alone will not overcome all reasons for nonuse, however: poor availability and access, provider biases, the general quality of contraceptive counseling and services, and the need for health system strengthening must also be addressed.

Presentation 4 Title / Titre de la présentation 4:

Breaking the Cycle of Unintended Pregnancy in Postpartum and Postabortion Women

Presenter of Presentation 4 / Auteur de la présentation 4:

Carolyn Curtis, United States Agency for International Development

Presentation 4 / Présentation 4:

Postpartum and postabortion women are underserved and often-vulnerable populations with high unmet need for family planning. Nearly 40% of all unmet need for FP is in the first year postpartum. It could be reduced by 50% if FP were effectively integrated with childhood immunization programs. Because of poor integration of services women who are immediately postpartum or are receiving postabortion care (PAC) frequently are not offered effective FP at the same time and location where delivery or PAC services are delivered. Closely-spaced pregnancies increase risk for adverse outcomes in a subsequent pregnancy.

This presentation is based on findings from a literature review of application of high-impact practices (HIPs) for postpartum and PAC FP, as well as individual and organizational experience with provision of technical assistance, training and services.   

An analysis of DHS data from 27 countries found that although 95% of women in the first year postpartum do not desire another birth within the following two years, over two-thirds (65%) were not using contraception. Situational analyses from 17 countries found that 43% of women seeking PAC services were not using FP, nearly 20% had a previous induced abortion, and only 1 in 4 PAC clients left the facility with FP, though more than half desired it. When FP and immunization services were integrated in the Philippines, provision of FP services to postpartum women increased by 70%-80%. When PAC services were reorganized in Turkey, FP use increased from 65% to 97% within one year, and total and repeat abortions decreased. Decentralized PAC services at 193 facilities in 21 districts in Tanzania reached more than 17,000 PAC clients from 2007-2010, of whom 89% received FP counseling and 83% left with a FP method. Decentralized PAC services in 323 facilities in 23 districts of Senegal experienced a 36% increase in FP counseling (46% to 82%), and a fourfold increase (15% to 56%) of women leaving the facility with a modern FP method.

Focused, evidence-based practices for women who are postpartum and postabortion can lead to sustained improvements in FP uptake and reduction of unmet need. These include reorganizing services to provide FP counseling and methods at the same time and location where women receive treatment for abortion-related complications; decentralizing PAC services; and offering FP services to postpartum women during routine childhood immunization. Such practices can prevent unwanted pregnancy, rapid repeat pregnancy and unsafe abortion, and thus decrease maternal morbidity and mortality.


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