Family planning data: whose interests are being served?

By Rebecca Oas, Ph.D. | February 24, 2016

A major flaw in the concept of the “unmet need” for family planning is that it reduces the question of whether one desires to become pregnant to a simple yes-and-no question. It then interprets a “no” as an equally non-nuanced desire for and willingness to use a modern method of family planning. “Unmet need” then undergoes a further contortion at the hands of family planning groups, who equate it to a lack of access to those modern methods, despite the fact that it makes no attempt to measure access. In fact, further survey data show that less than a tenth of women with “unmet need” claim a lack of access.

The frequency with which family planning advocates wrongly conflate “unmet need” and “lack of access” suggests that this common misperception may be seen as benign, or even beneficial, by those who know better.

The collection and analysis of data around family planning/contraception has long and almost exclusively been conducted by organizations seeking to promote the uptake and use of contraceptives. From the early fertility surveys conducted in the United States to the international “KAP” surveys of the mid-twentieth century, the goal was to study fertility in order to reduce it, and to study contraception in order to increase it.

The “unmet need” concept was brought in ostensibly to expand the family planning rationale to include women’s empowerment and increased decision-making ability. But women’s rights advocates who were placated in the 1990s by the increased emphasis on “voluntary access” to family planning services should be wary: while women’s rights are purportedly still a high priority, new trends in family planning data collection reveal a systematic erosion of emphasis on women’s voices and preferences.

The shift is subtle: a woman is asked if she would like to be pregnant in the next two years, yes or no? There used to be follow-up questions about how happy she would be or how big of a problem it would be if she found out she was pregnant shortly thereafter – these were discontinued in 2003, reducing the question to a simple binary. The reason for this exclusion was attributed to inconsistently collected data in one instance and lack of interest or enthusiasm by analysts in another. Nevertheless, the researchers who did analyze this nuanced data found high levels of willingness to accept a child in the near future, even if the woman had previously stated she would just as soon avoid pregnancy. But this finding is of relatively little interest to those whose primary goal is to drive up contraceptive prevalence.

In general, if a woman can be classified in a survey as desiring to avoid or postpone pregnancy—even if that desire is relatively weak or offset by other competing desires—the family planning machine immediately seizes on that data point as an unqualified mandate to ensure that the woman remains sterile by any means necessary.

To give a recent example: the current surveys used to collect data on international contraceptive use and reproductive preferences at country level include the Demographic and Health Survey (DHS), which is a project of the U.S. government. Last September, DHS released an analytical paper titled “Uptake and Discontinuation of Long-Acting Reversible Contraceptives (LARCs) in Low-Income Countries.”

Contraceptive discontinuation is a matter of some frustration to family planning groups, as illustrated by this “leaking bucket” analogy from the Population Council that I’ve written about before:

Bucket

Among the findings of the DHS paper:

The two [long-acting] methods that require provider removal, IUDs and implants, have the lowest discontinuation rates.

This is in comparison to modern non-LARC methods and the contraceptive injection, the LARC that does not require removal by a provider.

Cost or access is infrequently cited as an issue in discontinuation of any method.

…indicating that discontinuation is a voluntary choice.

Four in ten episodes of LARC discontinuation are attributed to side effects or health concerns, more than double that of other modern methods combined.

Bear in mind that this is discontinuation, not refusal to initially adopt the method, which suggests that the side effects are actual, not theoretical, and that the woman is more willing to accept increased risk of pregnancy than continue to experience the side effects.

According to the paper,

High levels of [discontinuation while still in “need” of family planning, abbreviated DWSIN] suggest method dissatisfaction and may leave women vulnerable to unwanted pregnancies if they do not start a new method.

While discontinuation is certainly indicative of dissatisfaction, especially if access is not an issue, it’s not necessarily true that continued use indicates a satisfied user. The common trait of the two least-discontinued methods was not user satisfaction, but the necessity of assistance in discontinuation. Depending on how onerous it is for a woman to find a provider to remove an IUD or implant, or how painful she anticipates the removal will be, it might take higher levels of dissatisfaction to convince her to do so.

The bulk of the paper focuses on modeling the “hazard” of DWSIN in different contexts, taking it as a given that discontinuing contraceptive use for any reason other than desiring a pregnancy is something worthy of characterizing as a “hazard.”

The problem with this approach is that it pits one form of a woman’s expression (her response to survey questions) against another (her decision to discontinue use of a contraceptive method) and assumes that the former is more valid than the latter. If, within the same survey, a married woman says that she a) would prefer to avoid pregnancy and b) has a personal opposition to contraceptives, she is characterized as having an “unmet need” that her personal or religious views form a “barrier” to satisfying. She chooses to use a contraceptive? That’s empowerment. She might choose to discontinue? That’s a “hazard.”

All this begs the question: whose interests are family planning groups, and their methods of data collection, trying to serve? If avoiding DWSIN is seen as paramount (despite clearly not being seen as such by the women who choose to discontinue), it will only fuel efforts to promote family planning methods that are more difficult to drop, creating a new class of barriers for women: not to get onto the family planning bandwagon, but to get off of it.

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