The Family Planning Transition:
Getting From Unmet Need to Met Need
Scott Radloff, PhD, Gates Institute
Roy Jacobstein, MD, MPH, MFA, Independent Consultant
Carolyn Curtis, CNM, MSN, FACNM, USAID Office of Population & Reproductive Health
Department of Population, Reproductive, and Family Health Seminar
Presentation venues
•
•
•
•
•
•
FIGO Triennial Congress, Rome, October 2012
Intn’l Conference on FP, Addis Ababa, November, 2013
USAID Global Health Mini-U, Washington, March 2014
Intn’l Confederation of Midwives, Prague, June 2014
Tanzania Semi-annual FP Partners mtg, Dar Es Salaam, August 2014
American College of Nurse-Midwives, 2015
International consensus statements
• Importance of Voluntary Family Planning & Its Provision by Our Members
• Post Abortion Family Planning: A Key Component of Post-Abortion Care
• Statement for Collective Action for Post-Partum FP
2
Outline of presentation
• Unmet need
– Definition
– Relation to total demand and contraceptive use (CPR)
– Global, regional, and country data
– Method mix and method effectiveness
• “Reservoirs” of unmet need (strategic opportunities)
– Reproductive intentions: delayers (youth) / limiters
– Service and program considerations: Task-shifting/task-sharing;
integration with postpartum services, PAC, and MCH
• What’s at stake
Definition of unmet need
Definition of unmet need:
Women who want to postpone a next birth for two years or
more or to limit further childbearing but are not using an
effective method of FP.
Unmet need + met need (CPR) = Total demand for FP
Modern CPR, unmet need for modern FP
and % of total demand satisfied, by region
Region
Modern
method use
(MCPR)
# of women
using modern
FP (millions)
Women with
unmet need for
modern FP
(%)
Women with
unmet need
for modern FP
(millions)
Proportion of
total demand
satisfied
Dev. regions
55%
645m
19%
222m
74%
Asia*
62%
515m
17%
141m
79%
Africa
25%
51m
28%
59m
46%
Latin America
66%
80m
19%
23m
78%
* Source: “Adding It Up,” Guttmacher Institute and UNFPA, 2012. Data are for married women .
Time trends: A greater proportion of total demand
is now being satisfied, in all regions …
80
70
60
50
40
30
20
68%
World
75%
% of demand
satisfied (met)
76 Total demand
70
Percent Demand Satisfied:
increased from 68% to 75%
over twenty year period.
57 MCPR
48
22
19
10
Unmet need
68%
0
1990
2010
90
80
Latin America
78
70
60
Percent Demand Satisfied:
increased from 68% to 80%
over twenty year period.
50
% of demand
Satisfied (met)
84 Total demand
67 MCPR
53
40
30
20
25
10
Source: Alkema, et al, Lancet, 2013
data for married women.
80%
0
1990
17
Unmet need
2010
… including Africa
90
80
70
60
50
73%
Asia
71
52
79%
% of demand
satisfied (met)
78 Total demand
Percent Demand Satisfied:
increased from 73% to 79%
over twenty year period.
61 MCPR
40
30
20
19
10
17 Unmet need
0
1990
Africa
2010
29%
60
50
Percent Demand Satisfied:
increased 18% over 20-year
period, MCPR doubled, yet
unmet need fell only 2%.
Source: Alkema, et al, Lancet, 2013.
Data for married women.
40
30
20
10
47%
% of demand
satisfied (met)
54 Total demand
44
31
13
29
25
0
1990
2010
Unmet need
Modern use
Time trends in two successful African countries:
MCPR & % demand satisfied rising markedly, unmet need falling somewhat
% Demand
satisfied
Rwanda
22%
18%
12%
Ethiopia
13%
64%
27%
% Demand
satisfied
51%
58%
80%
59%
50%
46%
44%
56%
70%
60%
45%
46%
6%
50%
40%
25%
13%
70%
10%
30%
20%
10%
1992
2000
Total demand for modern FP
Met need (Modern CPR)
Unmet need for modern FP
2005
2010
0%
2014
Data Sources: DHS surveys for Rwanda; DHS surveys and PMA 2014 for Ethiopia. Data for MWRA.
“… We call upon other African leaders to increase funding for FP commodities and related services from national
budgets.” www.thelancet.com July 10, 2012
—Pierre Damien Habumuremyi Prime Minister, Govt of Rwanda
— Meles Zenawi Prime Minister, Govt of Ethiopia
Similar positive trends in Tanzania
(had been concern about slow fall in unmet need)
% of demand satisfied
17%
31%
36%
42%
51%
Tripling of % FP demand satisfied:
60%
51%
50%
40%
42%
36%
30%
31%
20%
17%
10%
0%
Total demand for modern FP
Met need (use of modern FP/MCPR)
Unmet need for modern FP
Data Sources: Respective Tanzania DHS surveys. Data are for currently married women.
Method mix in Tanzania
mCPR = 27
Female
sterilization
10%
Traditional
24%
Pill
19%
Male condom
7%
Source: 2010 Tanzania DHS survey, married or in-union women.
IUD
2% Implants
7%
Injectables
31%
Tanzania: Method mix by reproductive intention
to space or limit
Method mix among limiters: greater reliance on clinical methods
Spacers
Limiters
LAM
4%
Traditional
20%
IUD
1%
LAM
2%
Implant
7%
Injectable
31%
Condom
18%
Pill
19%
Traditional
15%
Condom
9%
Pill
16%
Female
sterilization
23%
IUD
2%
Injectable
27%
Implant
6%
Data Source: 2010 Tanzania DHS survey.
Secondary analysis conducted by the RESPOND Project. Data is for all women.
Two quiz questions for you
1) How effective is withdrawal compared to no
method use?
2) In typical use, how much more effective is an
implant than an injectable? Why?
Method effectiveness in typical use
(i.e., programmatic / actual use; key consideration for users)
Method
Failure
rate (%)
# unintended pregnancies
per 1,000 women
In first year of typical use
Implant
0.05%
0.5
Vasectomy
0.15%
Relative effectiveness
(notes and comments)
1 pregnancy per 2,000 women
5-yr failure rate: 1.1%
1.5
Depends on the skill of the operator
Non-hormonal, “one-and-done,” safer and
easier than FS, almost all men eligible
Also “one-and-done”. But “permanent”
does not mean “infallible”: 5-yr failure: 1.3%:
Almost all women are eligible to use it
Female sterilization
0.5%
5
IUD (Cu-T)
0.8%
8
Injectable
6%
60
Pill
9%
90
Male condom
18%
180
Withdrawal
22%
220
No method
85%
850
LNG-IUS failure rate: 0.2%
An implant user is 120x less likely to
have an unintended pregnancy than an
injectable user in 1st year of typical use
4-fold higher effectiveness than no
method
Data Source: Trussell J. Contraceptive failure in the United States. Contraception 2011; (83).
Rising implants use in Africa
(even before commodity price reductions of FP2020)
Contraceptive Prevalence Rate
for Implants
7
Sub-Saharan African countries with implant CPR above 2%
6.3%
6
5
4
3.4%
3
2.7%
2.5%
2.3%
3.4%
2.7%
2
1.2%
1
0
0.5%
2004 2010
Tanzania
1.2%
0.3%
0.1%
2006 2012/13
2005/06 2010/11
Mali
Zimbabwe
0.2%
2006 2011
2003 2010
2005 2011
Uganda
Burkina Faso
Ethiopia
All data are from the Demographic and Health Surveys (DHS), for women ages 15-49 currently married or in union.
0.4%
2005 2010
Rwanda
Major “reservoirs” of unmet need:
(A.k.a. major opportunities for strategic FP programming)
• Youth (married and unmarried)
• Women and men with reproductive intention to limit births
• Discontinuers
• Postpartum women
• Women who are post-abortion (PAC FP)
Latest U.S. recommendations regarding LARCs, young
women and unintended pregnancy
The American College of Obstetricians and Gynecologists recommends that its members
“encourage adolescents age 15-19 to consider implants and IUDs as the best reversible
methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in
young women.”
--ACOG Committee Opinion #539, Obstet. Gynecol., 2012; 120(4):983-988
“Given the efficacy, safety, and ease of use, LARC methods should be considered
first-line contraceptive choices for adolescents.”
“Pediatricians are encouraged to counsel adolescents in…order…from most to least
effective, starting with the long-acting reversible contraception, LARC.”
--American Academy of Pediatrics Policy Statement: Contraception for Adolescents,
Pediatrics 2014, published online September 29, 2014
The “youth bulge” in Africa:
Increasing
Sequential Age Pyramids for Sub-Saharan Africa
in 1960, 1990, and 2010
80-84
70-74
60-64
50-54
Male
Female
40-44
30-34
20-24
10-14
0-4
-80,000
-70,000
-60,000
-50,000
-40,000
-30,000
-20,000
-10,000
80
70
60
50
40
30
20
10
0
0
10,000
10
20,000
20
Number for each age-group (millions)
Source: World Bank
30,000
30
40,000
40
50,000
50
60,000
60
70,000
80,000
70
80
Young married women:
High total demand for FP and high unmet need
West and Central Africa
15-19
+
= Total Demand for FP
80
90 100
Current use (includes traditional methods)
Unmet need for FP
20-24
East and Southern Africa
15-19
20-24
Asia
15-19
20-24
Latin America and Caribbean
15-19
20-24
0
10
20
30
40 50 60
Percentage
70
Source: Adapted from presentation by K. MacQuarrie, Measure DHS, Futures Institute, at Wilson Center, 9/17/13.
Demand and unmet need for FP is even higher in young,
unmarried sexually-active women (~20% of total unmet need)
+ = Total demand for FP
West and Central Africa
Current use (includes traditional methods)
Unmet need for FP
15-19
20-24
East and Southern Africa
15-19
20-24
Latin America and Caribbean
15-19
20-24
0
10
20
30
40 50 60
Percentage
70
80
90 100
Source: Adapted from presentation by K. MacQuarrie, Measure DHS, Futures Institute, at Wilson Center, 9/17/13.
Reproductive intentions and the demand to limit
(Key points sometimes underappreciated, even by “us”)
• Major global megatrends are driving smaller desired family size:
the small family norm is becoming universal
• Millions of women and couples now spend ½ to ⅔ of their 3-decade
reproductive lives as “limiters”
• Demand to limit exceeds demand to space among MWRA in every
region except West Africa and Central Africa
• Average age at which demand to limit exceeds demand to space
(“crossover age”) is falling, to as low as 23 or 24 in some countries
• Does not equate to need for permanent methods -- but many would
and do choose them (>250 million use a PM; FS most widely used method in world:
> 220 million women / 19% CPR among MWRA)
Reproductive intentions and MCPR,
selected countries by demand to limit
Modern method use
(MCPR, %)
Demand
to space (%)
Demand
to limit (%)
Brazil (1996)
77
18
70
Colombia (2010)
73
22
65
India (2005–06)
49
11
58
South Africa (2003)
60
19
55
Bangladesh (2011)
52
22
53
Indonesia (2010)
58
30
45
Kenya (2008–09)
39
30
42
Rwanda (2010)
45
33
46
Malawi (2010)
42
33
40
Pakistan (2012-13)
26
18
37
Madagascar (2008-09)
29
29
30
Ghana (2008)
17
34
25
Ethiopia (2011)
27
33
22
6
33
12
10
29
11
Country
DR Congo (2007)
Nigeria (2013)
Sources: Most recent DHS survey for each country when year indicated; otherwise, UN, 2014. Data for married or in-union women.
Discontinuers – implies need for programs to focus on quality,
better counseling, anticipatory guidance, side effects management
• Youth (married and unmarried)
• Women and men with reproductive intention to limit births
• Discontinuers: Women who used FP in the past, and now use no method
though they do not want to become pregnant: 38% of total unmet need
• Postpartum women
• Women who are post-abortion (PAC FP)
Thank you!