“Unmet Need” 2.0: Carrot, Stick, or Spoonful of Sugar? Moving from Access to Uptake

By Rebecca Oas, Ph.D. | July 14, 2014

(This is the third and final part of a series examining the so-called “unmet need” for contraceptives in the developing world.  Part one can be found here and part two is here.)

As summarized in the previous installments, the “unmet need” concept has been used to frame overpopulation alarmism in the language of women’s rights.  Nonuse of contraceptives is redefined as an unmet need, which is then rephrased as unfulfilled demand or, most frequently, lack of access.  Access, in turn, is framed as a human rights issue.

Access: an advantageous misconstruction

“Access” is a very important concept for advocacy efforts:  if ensuring access to something is paramount, then nothing can be allowed to stand in the way, including the conscience of anyone who is (or even could be) involved in its provision.  This question was recently debated in the US Supreme Court in the Hobby Lobby religious freedom case.  On its face, access seems inoffensive in that it implies no coercion to actually use the accessible thing.  But the flip side of the coin is mandated complicity in making the thing accessible.  Even if there are no users, there still must be providers.

Furthermore, when it comes to contraceptives and other controversial things, merely having providers is still not enough – access must not only exist, but it must be ubiquitous in order that it become accepted, and, ultimately, used.

The papers in the recent series on unmet need in Studies in Family Planning were first presented at a conference in Kenya titled “Is Access Enough? Understanding and Addressing Unmet Need for Family Planning.”  Clearly, the participants’ answer is that access is not enough – not when only 4-8% of “unmet need” is access-related.

Of course, as the authors of the papers are quick to point out, the definition of “unmet need” doesn’t actually involve access at all.  Bradley and Casterline write:

“Often asserted is that estimates of unmet need represent the proportion of women who want to practice contraception but are prevented from doing so by inadequate access to supplies and services. As we demonstrate below, however, the standard algorithm does not include any direct measures of the desire to practice contraception or any direct measures of access to contraception.”

In practice, this works out to false advertising covered by plausible deniability.  Advocacy groups parrot the meme that women a) want contraceptives and b) have no access to them, and donors send them money.  When skeptics point out that access is greater and demand is lower than the advocates will admit, the scholars behind the “unmet need” concept are able to stand at a safe distance and defend their much-misinterpreted creation by technicalities.

Selective hearing

If the “unmet need” definition doesn’t attempt to measure women’s desire for contraceptives or their access, what exactly does it measure? Simply put, it uses questions and answers from the Demographic and Health Survey (DHS) to determine whether a women who is married (or in non-marital union), sexually active, and presumably fecund wants to have a(nother) child in the next two years, and if not, if she is using a modern contraceptive to avoid it.  If she is not, the survey inquires as to why not.

The exact formulation has undergone changes over the years, but one thing that has been eliminated is any question regarding the intensity of a woman’s feelings regarding the prospect of pregnancy.  Older versions of the survey asked how “happy” she would be if she became pregnant, or how much of a “problem” it would be, according to an intensity scale.  Removing these indicators means that the questions about whether the woman wants to have a child fall into the realm of “all other things being equal.”

However, all other things are not equal, as evidenced by the range of answers to the question about why women aren’t using contraceptives despite their alleged “unmet need.”  Some women and their partners express a religious or cultural opposition to the use of contraceptives – a rationale that will not be swayed by increased availability or improved formulations.  But the most frequently cited reason for nonuse of modern contraceptives was concern over side effects.

“Reluctance to try contraceptive methods because of fear of side effects or health risks can also be argued to be, in part, a consequence of insufficient or erroneous information,” write Cleland, Harbison and Shah.  They note that when barriers to access and lack of knowledge are addressed, concerns about adverse health effects persist – in regions with both high and low levels of contraceptive use.  They also admit that these concerns can’t be explained away in terms of rumors and hearsay: “in high-use countries these concerns are more likely to be based on personal experience than on perceptions.”

These are women who have already indicated via DHS questionnaires that they are not looking to have a child in the next two years, yet their concern about the side effects of contraception clearly outweigh their concerns about the impact of childbirth or parenting.  Given that these women with “unmet need” disproportionately live in countries with high levels of poverty and high maternal mortality rates by global standards, it is important to look at their answers in context.  They have weighed the costs and benefits of contraception against the very real possibility of a risky birth and another mouth to feed and chosen to forego contraception.  All things are not equal, and while they may not have had a great desire – much less a demand – to be pregnant at that moment, they clearly weren’t sufficiently opposed to the idea of pregnancy to avoid it by state-of-the art family planning.

Whose choice anyway?

To family planning advocates, access is just the beginning: acceptance and ultimately uptake are the end goal.  Like good salesmen, they believe in their product and want to encourage its consumption, but unlike most merchants, their primary funding isn’t dependent on convincing average people to pay for their offerings: that’s what philanthropists and wealthy donor states are for.  These funding streams cover not only the manufacture and distribution of contraceptive commodities, but also a wide variety of targeted marketing campaigns.  As John Bongaarts writes:

“With a given level of demand, an increase in [contraceptive] use produces a corresponding decline in unmet need. The evidence also shows, however, that programs can have a second effect by raising the demand for contraception. This effect is expected according to diffusion theory and may be attributed to program [information, education, and communication (IEC)] messages concerning the benefits of family planning and the diffusion of ideas about them.”

Further, Cleland, Harbison, and Shah add:

“[S]ocial opposition and, to a lesser extent, lack of knowledge are important barriers to contraceptive uptake in such settings. Skilled use of mass media, together with more localized approaches targeting influential groups—such as school teachers and traditional and religious leaders—are required to disseminate information concerning methods and defuse initial opposition.”

In other words, where religious objections exist, the most effective way to bypass it is to co-opt local religious leaders and recruit them to promote contraception.

Another paper in the series examines the use of natural methods of family planning and concludes that designers of family planning programs “may underestimate the dislike for modern methods, attributing the nonuse of contraceptive technologies to problems of access or lack of education, rather than a negative perception of modern medical contraception.”  The authors do suggest that family planning advocates might consider promoting some natural methods, but then double down on the need to reprogram women’s thinking:

“These results highlight the need for large-scale behavior-change communication to debunk misinformation concerning modern medical contraception, complemented by changes in family planning counseling so that women can be reassured on a one-to-one basis.”

But “large-scale behavior-change” is not a terribly appealing thing to offer to women in developing countries, particularly when it is targeted toward getting them to discard aspects of their religion or culture that don’t sit well with the population control crowd.

The architects of “unmet need” are masters of rebranding, though: Cleland, Harbison, and Shah refer to “the acceptability of contraception and associated services” – which almost certainly includes abortion – with the phrase “psychosocial access.”

You have to hand it to them for cleverness – it’s hard to envision a better way to characterize a woman’s moral objections to freely available contraceptives as a problem of lack of access.