Original research articleMeasurement of unmet need for family planning: longitudinal analysis of the impact of fertility desires on subsequent childbearing behaviors among urban women from Uttar Pradesh, India
Introduction
A common indicator used to measure a population's need for family planning (FP) services is “unmet need.” This indicator has been defined in the global FP world to be the percentage of sexually active, fecund women who say they want to delay or stop childbearing and are not using any form of FP. Recent estimates of unmet need demonstrate that the proportion of women with an unmet need varies cross-nationally with the highest unmet need in sub-Saharan Africa and slightly lower unmet need in Asia where current FP use is higher [1]. FP offers a number of health benefits through reduction of unintended (mistimed and unwanted) pregnancies [2], [3], [4]. These benefits include reduced spread of HIV to newborns [5]; reduced maternal mortality and morbidity [6], [7]; reduced neonatal, infant, and child mortality [8], [9]; reduced recourse to often unsafe abortion [6], [10]; and improved education and employment opportunities for women (and men) who are able to delay initiation of childbearing [6].
Although unmet need is a useful measure at the policy level, it is less useful at the individual level because it relies on reported fertility desires that have been found to often be fluid, fluctuating in response to changing individual, relationship, and community influences [3], [11], [12]. The fluidity of fertility intentions could partially explain documented inconsistencies between women's stated pregnancy intentions and subsequent childbearing experiences [13]. For example, a 1970s French study demonstrated that, among women who intended a birth in the future, 73% had a birth in the 5-year follow-up period [12]. More notably, among those women who did not intend to have any more children, about 20% had a birth in the 5-year follow-up period. Similarly, longitudinal studies from Nigeria and Morocco demonstrated that 16% and 29%, respectively, of women who reported that they did not want any more children had a birth in the 2-year follow-up period [11], [14]. Likewise, a study from Bangladesh found that 17% of couples that did not want any more children had a child in the 5-year follow-up period [15]. Furthermore, a study from India, the site of the current study, showed that 61% of fecund women who reported that they did not want any more children experienced a child in the 6–7-year follow-up period; this high percentage may reflect the longer follow-up period or fatalistic views about childbearing in the study context [16]. These observed inconsistencies between fertility intentions and childbearing experiences raise questions about the measurement of unmet need.
The gap between reported fertility intentions to avoid or delay pregnancy and actual FP use may reflect the host of well-documented cost, access, cultural barriers impeding uptake and sustained use of effective FP [9], [17], [18], [19]. In addition to these barriers to FP use, ambivalent fertility desires must also be considered as part of discussions around measuring unmet FP needs [20], [21]. A recent study from Indonesia demonstrated that women who were ambivalent about future childbearing, that is, they reported that they did not know whether they desired another child, had birth experiences in the 4-year follow-up period similar to women who reported that they did not want any more children [22]. In particular, 33% of ambivalent women had a birth in the 4-year follow-up compared to 29% among women who did not want a child and 57% among women who wanted more children. Conversely, in terms of FP use, ambivalent women were more similar to the women who wanted more children; FP use was not predictive of ambivalent women's subsequent birth outcomes [22]. Where pregnancy ambivalence is common, measurement of unmet need may be over (or under) estimated given that it relies on fertility desires as a key component of its calculation.
Our study contributes to prior discussions of the measurement of unmet need by examining fertility desires and subsequent childbearing behaviors using novel data from a 2-year follow-up study among urban women from Uttar Pradesh, India. Our focus on urban women in India contributes to prior longitudinal research from India that included women from rural areas [16], [23]. The objectives of the study are twofold. First, we determine whether baseline fertility intentions and FP use are associated with women's pregnancy experience over the 2-year follow-up period. Second, we determine the intentionality of pregnancies at follow-up to determine whether baseline fertility intentions are associated with the reported intentionality of pregnancies experienced in the 2-year follow-up period. The hypothesis is that if fertility desires are firm, those women who reported at baseline that they did not want any more children would be more likely to report the pregnancy/birth during the follow-up period as unintended (wanted later or did not want) than those women who reported that they wanted more children at baseline. Moreover, we expect that those women who were using FP at baseline would be more likely to report the pregnancy as unintended. The results provide insights for measuring unmet need through examination of the reliability of stated fertility desires and the relationship between fertility intentions, FP use, and pregnancy experience.
Section snippets
Materials and methods
Data for this study come from four cities (Agra, Aligarh, Allahabad, and Gorakhpur) in Uttar Pradesh, India. The data were collected by the Measurement, Learning & Evaluation Project as part of mid-term data collection for the evaluation of the Urban Health Initiative, implemented by FHI360 with funding from the Bill & Melinda Gates Foundation. Baseline data were collected in early 2010 from a representative sample of 17,643 married women from six cities; the baseline survey has been described
Results
Table 1 presents the percent distribution of background characteristics by interview status of the 6752 women that were selected for re-interview in 2012. At mid-term, data were collected from 85.8% of the eligible mid-term sample. Across the demographic characteristics, more than 80% of the sample was re-interviewed. Notably, we were able to interview a higher percentage of the older women than the younger women; this might reflect greater mobility of younger women/couples. Correspondingly,
Discussion
These findings are important for understanding the use of unmet need to determine gaps in FP program coverage. In our study context, we found that women who do not want any(more) children and are using any FP method are the least likely to experience a pregnancy/birth in the 2-year follow-up period. Moreover, women who do not want any(more) children who are non-users of FP were also less likely to experience a pregnancy/birth in the follow-up period. Conversely, the stated desire to delay
Acknowledgments
Funding for this work comes from the Bill & Melinda Gates Foundation. This research was also supported by grant 5 R24 HD050924, Carolina Population Center, awarded to the Carolina Population Center at The University of North Carolina at Chapel Hill by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The contents of this paper are solely the responsibility of the authors and do not necessarily represent the official views of the funders. Reprints can be
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