They are two of the most common indicators in the field of family planning. “Unmet need” and “demand satisfied” are key metrics used by governments, donors, advocates, and UN agencies to track the need for modern contraception. But what do they actually measure? And are “need” and “demand” the right words to use?
In a just published commentary in Global Health: Science and Practice, the FP2030 Performance Monitoring and Evidence (PME) Working Group suggests that now is the time to revisit these important indicators. Using a human rights and reproductive justice lens, the PME Working Group calls on the family planning community to agree on more accurate labels for these indicators and eventually to work toward developing more refined measures that do a better job of capturing people’s fertility intentions and preferences.
As it stands, both “unmet need” and “demand satisfied” are frequently misunderstood and misused. The current labels are confusing and disguise the fact that what is being measured may not be what people really need or want in terms of contraception.
Take “unmet need for family planning.” It’s defined as the percentage of (fecund, sexually active) women who do not want to become pregnant but are not using contraception. What’s left out of the equation is whether these women want to use contraception. In fact, about half of the women classified as having “unmet need” (because they aren’t using contraception) nevertheless report that they do not want or intend to use contraception in the future. This is a valid choice: Everyone has the right to use or not use contraception as they see fit. But is it appropriate to describe these individuals as having “unmet need”?
“Demand satisfied for family planning” (along with “total demand for family planning”) suffers from similar issues. It considers all women with “unmet need” to have a “demand” for contraception, even when that is clearly not the case. It further considers this demand to be “satisfied” by any method (or any modern method), regardless of whether the individual is happy with the method or has a full range of methods to choose from. As with the “unmet need” indicator, the language implies that people’s desires and preferences are being reflected, when in fact they are not.
Sometimes these indicators are framed in terms of modern contraception only, as in the Sustainable Development Goals indicator of “demand satisfied with modern methods” (Indicator 3.7.1) and the FP2030 country indicators of “unmet need for modern methods” and “demand satisfied with modern methods.” The implication is that people who are using traditional methods of contraception are in need of a modern method. But are they? For some people, the decision to use traditional methods is a well-considered choice, completely in line with their reproductive intentions and preferences.
Another issue is the pool of users or potential users being counted. The “unmet need” and “demand satisfied” indicators assume that all married women are at risk of pregnancy, which is demonstrably untrue. Some married women may not be sexually active, or their partners may be away, and they may only occasionally use contraception. Do they have an “unmet need” if they are not at risk of pregnancy? What about women who have reasons for using contraception that are not related to fertility such as menstrual regulation or prevention of a sexually transmitted infection? Does our measurement correctly capture their needs?
As a first step toward greater clarity and accuracy, the PME Working Group proposes changing the labels of the existing indicators to better reflect what is being measured. “Unmet need,” for example, could be retitled “percent of women who want to avoid pregnancy but are not using contraception.” For the “demand satisfied” indicator, a more accurate title would be “percent of women using contraception among women who say they do not want to get pregnant.” These are suggestions; the PME Working Group invites discussion across the field of how best to relabel the indicators.
Beyond the language issue, the PME Working Group calls on the community to consider changes and additions to the indicators themselves. This will require not only thorough evaluation of the conceptualizations underlying family planning measurement, but also formative research on women’s, men’s, and couples’ motivations, aspirations, and preferences that surround fertility intentions and contraceptive use.
In a commentary published alongside the PME Working Group article, Madeleine Short Fabic, associate editor of Global Health and supervisory public health adviser for the United States Agency for International Development (USAID), responds to the call for action and drills down on family planning’s use of the terms “need” and “demand,” which were originally borrowed from economic theory. To support a more nuanced understanding of the demand for family planning, she defines four interrelated yet distinct desires: reproductive autonomy, pregnancy prevention, contraception, and a specific contraceptive method. Each implies its own questions and potential indicators.
Family planning measures and language have evolved over decades, so change will take time. The PME Working Group encourages more conversations about “need” and “demand” measures and over the coming years FP2030 will support more discussion and action on these and other measurement challenges.