Why Confusion About Family Planning Terminology Could Be Costing Us Billions

By | June 15, 2019

INTRODUCTION

At international institutions, there is always a politically sensitive, if not controversial, nature to discussions of sex, reproduction, and the family.  Even so, since 1968, some nations have framed such matters as rights by promoting the idea of a “human right” to family planning. Since then, and most recently in the Sustainable Development Goals adopted by the UN General Assembly in 2015, nations have accepted political commitments to guarantee their people “access” to family planning. What is most important for this examination is that, despite these commitments, there has been little clarity on what that specifically means. As a result, perverse incentives for using commodities to control pregnancy and childbirth can lead to real harm. This is largely due to the political enthusiasm, national power, and international funding for family planning, which has far exceeded the actual demand for it by women and couples on the ground.

The implications of this manufactured confusion go beyond academic discourse.  The Sustainable Development Goals carry a massive price tag of  $5-7 trillion dollars a year over fifteen years.  There are many entities competing for their piece of that pie, and family planning groups are working hard to ensure their issue remains prominent.  They have made the case that family planning is the key to achieving the SDGs because of the ripple effects that demographic shifts can have across multiple issue areas.  

How to measure access

In an effort to ensure the “voluntary” nature of contraception among the poor, population experts—including sociologists, political economists, and population control advocates—have used the concept of an “unmet need” for family planning as the proxy measure for access to it.  Used in various forms for decades by population researchers, the term, “unmet need”, achieved prominence in 1994 when it was explicitly included in the agreed conclusions of the International Conference on Population and Development.  It has been characterized as “an invaluable bridge between a human rights and feminist approach to fertility control and a demographic–economic rationale.”  Yet “unmet need” is not a measure of access, but includes any woman who is not currently using a method of family planning and has stated a desire to avoid pregnancy in the near future. 

As demography scholars, Sarah E.K. Bradley and John B. Casterline, observed,  “The standard algorithm does not include any direct measures of the desire to practice contraception or any direct measures of access to contraception.”  In fact, when women defined as having an “unmet need” are surveyed about why they are not currently using a method, only about five percent name lack of access as the reason.  They also pointed out in an earlier analysis on the same topic, “[t]he evidence presented here makes clear that access to contraceptive supplies is not sufficient as a means to satisfy unmet need for contraception.”

While it may be true that access does not guarantee the use of contraception, the international agreement is to ensure universal access, not the elimination of “unmet need.”  This distinction is particularly important when considering that the predominant reasons for “unmet need” involve women’s and couples’ concerns about side effects and health risks, their personal opposition to contraception, their perception that they are unlikely to conceive, and various other reasons that are an exercise of free choice.

But “unmet need” remains an incredibly popular metric among family planning advocates, despite—or perhaps because of—its widespread misuse and misunderstanding.  Global health advocates such as Melinda Gates often cite a figure of more than 200 million women in developing countries with an “unmet need”. UN agencies, politicians, and family planning organizations have routinely misinterpreted this number, claiming falsely, that more than 200 million women lack access to family planning. This is inaccurate in ninety-five percent of cases, according to women surveyed.  The most egregious case of misleading the public is the United Nations Population Fund (UNFPA), which not only treats lack of access and “unmet need” as interchangeable, but also has defined “ending unmet need for family planning” as one of its three top priorities.

Access and use: distinct or interchangeable?

“Unmet need” has indeed been invaluable to family planning proponents by providing a critical step toward treating access to and use of contraceptives as nearly interchangeable concepts.  Similarly, it fuels the notion that non-use of contraceptives must be the result of a lack of access, and, therefore, not only an inconvenience, but a human rights violation.

For purposes of advocacy, this makes for great messaging.  For purposes of policymaking, it creates the potential for disaster.  Those who accept the notion that “unmet need” and lack of access are synonymous will believe the claims of family planning organizations like UNFPA and the Guttmacher Institute that contraceptive prevalence, and resulting reductions in fertility rates, can be achieved for the price of delivering commodities alone.  It is noteworthy that the Guttmacher Institute also published the best rebuttal to this argument—that this is only likely to be true in five percent of cases.

The Bill and Melinda Gates Foundation, like the FP2020 initiative Melinda Gates champions, elides the distinction between access and use.  The program was launched at a 2012 London summit with the ambitious goal to “reach 120 million more women and girls worldwide with access to voluntary family planning information, contraceptives, and services by 2020.”  However, the technical note explaining the goal translates it as “achieving 120 million new users.”  The presumption is that there are 120 million women and girls who are not using family planning due to lack of access.  

Additionally, in a technical critique, Aisha Dasgupta and colleagues challenged FP2020, not for equating use with access, but for the phrase “new users,” which led to confusion between whether it only meant first-time users or could include users who had previously used a method and discontinued it.  They emphasized the importance of providing continued service to current family planning users. Dasgupta noted that, in an exemplar of cart-before-the-horse thinking, women were aging out of their reproductive years and voluntarily discontinuing family planning in order to have children, and therefore,  “there will always be a need to reach [additional] adopters as part of the efforts to sustain existing contraceptive use in any given population.” 

From need to demand…and beyond

The “unmet need” concept has been criticized as paternalistic, better suited to advocacy than scholarly discourse, and “not correspond[ing] to what any economist would call demand.”  But demographers have dared to go where economists fear to tread: in a technical explanation on the website of the UN’s Population Division, “total demand” for family planning is defined as the sum of contraceptive prevalence and “unmet need.”

Words like “access,” “need,” “use,” and “demand” are commonly used, and may their meaning might seem simple to the average listener or reader, however, this analysis has shown that the opposite is true. When multiple disciplines converge, the lines between common usage and technical jargon blur.  This is only heightened when the words are specifically chosen and defined to maximize their effectiveness in advocacy.  

It makes logical sense that those who aim to increase contraceptive prevalence speak in terms of increasing access.  “Access” bespeaks voluntariness, personal liberty, and the fulfillment of international human rights agreements.  “Lack of access,” by extension, conjures up some violation of those rights.  On the other hand, speaking directly of fertility reduction by way of increased family planning usage hearkens back to the dark days of coercive population control—a shadow the modern family planning movement has worked hard to outrun.

To their credit, scholars working on issues of demography and family planning been serious about the need to measure things consistently and maintain an academically rigorous discourse in writings, however, the evidence of discipline-level bias remains: the phrase “improved contraceptive prevalence” is often used interchangeably with “increased contraceptive prevalence” in peer-reviewed articles.  Likewise, one frequently sees mention of the “risk” of pregnancy as opposed to “probability.”  These are value judgments, not empirical observations.

Outside academia, the existing standards fall away entirely.  From the paraphrasing of “unmet need” as “lack of access” to the baseless assumption that investing more funds in family planning will inevitably convince new (or discontinued) users to adopt methods, the verbal shell game employed by the family planning movement serves to hide one essential fact: the market is nearly saturated.

In a world where major donors are contemplating cuts to global development aid, where conflict and natural disasters create new challenges, and where resources are stretched thin, it is important to invest in the things that can make the most difference.  The argument that family planning is a “best buy” for accelerating progress on the SDGs becomes shaky when the gap between “access” and “use” is taken into account. There are true shortfalls in access to essential things like basic health care and infrastructure in the poorest regions of the world.  It is critical that much-needed resources not be siphoned away from these pressing needs and spent instead on products and services for which the actual demand has already been satisfied.

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