The Crucial Distinction between “Unmet Need” and “Unmet Demand” by William N. Ryerson

Motivation to use family planning and to limit family size has been the key missing element in the strategy for population stabilization.

There is a widespread view among many population activists that the top priority in the population field should be focused on providing family planning medical services because of the belief that lack of access to these services is the major barrier to fertility reduction.  It is true that over the last 40 years increasing access to contraceptive services has helped reduce fertility rates.  The view of those who subscribe to the “medical model” of solving the population problem is that additional family planning services will complete the job.

This is perhaps the most important issue within the population field. Of the money spent by developing and developed countries for population-related work in the developing world, the largest share has gone to providing family planning medical services to individuals and couples. Inherent in this approach is the belief that a large portion of births are unwanted and that contraceptive availability will solve this problem. Indeed, a significant percentage of births may be unwanted or mistimed, but large family norms/desires and the cultural and informational barriers to the use of contraception are now the major impediments to achieving replacement level fertility.

In Kenya, which was the fastest growing country in the world in the 1980s, contraceptives were within reach of nearly 90% of the population by the late 1980s.  Yet currently, only 39% of married women use them. That is only one example.

It is clear that providing contraceptive services alone will not solve the population problem. Since the late 1960s and throughout the 1970s, studies were conducted in numerous countries measuring women’s knowledge of, attitudes toward, and practice of birth control as well as their family size desires. These knowledge, attitude and practice studies resulted in the term “unmet need” to describe those women who wanted to delay their next pregnancy by at least two years but were not using a modern method of contraception. In the minds of many policy makers and funders, “unmet need” was equated with “lack of access” to contraceptive services. However, demographers Charles Westoff and Luis Hernando Ochoa, in a review of numerous Demographic and Health Surveys, determined that about half the women categorized as having an “unmet need” have no intention of using contraceptives even if they were made freely available.

The confusion between the term “unmet need” and “unmet demand” has misled many people in leadership positions to assume that such “unmet demand” could be overcome by improving family planning services and contraceptive distribution. The reasoning has been that, if there was a gap between what people want and what they are doing, improving access to contraceptives would close that gap. The problem is that the discrepancy between attitudes and behavior has had less and less to do with availability in recent decades.

The situation in Kenya is illustrative of findings in numerous countries recently. In Kenya, according to the 2008-09 Demographic and Health Survey, 96% of currently married women and 98% of husbands know about modern contraceptives. Of the married women who are non-users, 40% do not intend to ever use contraception. Among all non-using married women, 8% give as their reason the desire for more children. Among the reasons given for not using contraception by women who are not pregnant and do not want to become pregnant, only 0.8% cited lack of availability of contraceptives, and 0.4% cited cost. The top four reasons among those who are still fecund:

• concern with the medical side effects of contraceptives (31%);
• religious prohibition (9%);
• personal opposition (8%);
• opposition from the husbands (6%).

These are all issues that are best addressed by information and motivational communications. Certainly, counterfeit contraceptives exist, and they may have harmful effects, so improving the availability of reliable methods is important. So is informing women of potential side effects of methods they choose. But much of the fear of health effects is based on intentional misinformation campaigns by those oppoed to contraceptive use.

Country by country, the Demographic and Health Surveys show a similar pattern to that in Kenya: Lack of access is cited infrequently by those who are categorized as having an unmet need for family planning.

A 1992 paper by Etienne van de Walle showed that another factor is at play for many women and men—fatalism. Many people have simply not reached the realization that reproductive decisions are a matter of conscious choice. Many who did not particularly want another pregnancy in the near future still reasoned that God had determined since the beginning of the universe how many children they would have and that it did not matter what they thought or whether they might use a contraceptive, because they could not oppose God’s will.

For example, Pakistan’s 2006-2007 Demographic and Health Survey found that the most common reason for non-use of contraceptives is the belief that God determines family size. This answer was given by 28% of the respondents. Since the fertility rate in Pakistan is 3.6 and the mean desired number of children among currently married women is 4.1, it is clear that family size norms are also a major factor in driving high fertility.

The tradition of large families is a deciding factor in fertility rates in most of sub-Saharan Africa. For example, the 2008 Demographic and Health Survey in Nigeria, Africa’s most populous country with 170 million inhabitants, found that the average ideal number of children for married women was 6.7.  For married men, it was 8.5.  The fertility rate in Nigeria is 5.6 children per woman, which is below what people say they actually want.

Of all births in Nigeria, 87% were wanted at the time and another 7% were wanted, but not until later. Only 4% were unwanted. Nationwide, 67% of married women and 89% of married men know of at least one modern method of contraception. Yet only 10% of married women report they currently use modern family planning methods.

Changing this situation takes more than provision of family planning services. It requires helping people understand the personal benefits of limiting and spacing births—in health and wealth for them and their children. It also involves overcoming fear that contraceptives are dangerous or that planning one’s family is unacceptable. It requires getting husbands and wives to talk to each other about use of family planning—a key step in the process of using contraceptives.

Delaying marriage and childbearing until adulthood, and educating girls are critical components. According to a 2003 report by the Nigerian Population Commission, in northern Nigeria the mean age at first conception is 15 years.  Teen births increased 50% between 1980 and 2003 in Nigeria, mostly attributable to adolescents in the northern regions.

The above should not be interpreted as suggesting that the level of effort in providing contraceptive services be reduced. High quality, low cost reproductive health care services are an essential element of fertility planning. Both quality and quantity of contraceptive choices and services are in dire need of improvement throughout much of the developing world. And “stockouts” of certain methods are a problem in many countries. But access to family planning methods is not sufficient if men can prevent their partners from using them, if women don’t understand the relative safety of contraception compared with early and repeated childbearing, or if women feel they cannot take control of their own lives.

Many population planners measure progress on the basis of contraceptive prevalence rates. Use of effective family planning methods is critical, but will not result in population stabilization if desired family size is five, six or seven children.

Motivation to use family planning and to limit family size has been the key missing element in the strategy for population stabilization.  While the percentage of non-users of contraceptives has declined, various studies indicate that the actual number of adults not using contraceptives is greater than it was in 1960, a fact stemming from the enormous increase in world population over the past 50 years. Approximately 44% of the roughly 2.3 billion people of reproductive age who are married or in long-term unions currently use no modern method of contraception. This means there are about 1 billion adult non-users of contraceptive methods. It’s time to focus significant effort on motivating this group to use contraception for the purpose of achieving small family size.

In reality, there are about 600 million adults in marriages or long-term unions who are non-users of contraception specifically because they want additional children or as many children as possible. This group is more numerous than the 430 million men and women classified as having an unmet need for family planning, and they deserve a lot of attention via programs that role model the benefits of smaller family norms.

Nearly as important are the desired family sizes of the 1.3 billion users of contraception. In many countries, those who do use contraceptives still want more than enough children to replace themselves. Their goals, if achieved, will lead to continued high rates of growth.

Japan has achieved below-replacement-level fertility (1.5 children per woman) in a country where the oral contraceptive pill was illegal until recently. The United States achieved below-replacement-level fertility in the Great Depression, before the invention of most modern contraceptives. Similarly, fertility dropped to near-replacement level in the 19th century in Western Europe and the United States.

World Bank economist Lant Pritchett, in a 1994 article in Population and Development Review, concluded that family size desire is the overwhelming determinant of actual fertility rates. “The conclusion that follows from the evidence and analysis we presented,” he wrote, “is that because fertility is principally determined by the desire for children, contraceptive access (or cost) or family planning effort more generally is not a dominant, or typically even a major, factor in determining fertility differences.” According to Pritchett, desired levels of fertility account for roughly 90% of differences among countries in total fertility rates.

Reducing the demand for children—for instance, by giving girls more education—is vastly more important to reducing fertility than providing more contraceptives or family planning services.

 Bill Ryerson is founder and president of the Population Media Center (PMC). He has worked for more than 38 years in the fields of reproductive health and behavior change. To read about PMC and its exciting programs, go to <www.populationmedia.org/>