MEASURE DHS+ assists countries worldwide in the collection and use of data to monitor and evaluate

population, health, and nutrition program s. Funded by the U.S. Agency for International Development (USAID),

MEASURE DHS+ is implemented by ORC Macro in Calverton, Maryland.

The main objectives of the MEASURE DHS+ project are: 

1) to provide decisionm akers in survey countries with inform ation useful for inform ed policy choices, 

2) to expand the international population and health database, 

3) to advance survey methodology, and 

4) to develop in participating countries the skills and resources necessary to conduct high-quality

demographic and health surveys.

Information about the MEASURE DHS+ project or the status of MEASURE DHS+ surveys is available on the

Internet at http://www.measuredhs.com or by contacting: 

ORC Macro

11785 Beltsville Drive, 

Suite 300

Calverton, MD 20705 USA

Telephone: 301-572-0200

Fax: 301-572-0999

E-mail: reports@m acroint.com
DHS Comparative Reports No. 1

Unmet Need at the End of the Century

Charles F. Westoff

September 2001

ORC Macro

Calverton, Maryland USA
Recommended citation:

W estoff, Charles F. 2001. Unmet Need at the End of the Century. DHS

Comparative Reports No. 1. Calverton, Maryland: ORC Macro.
iii

Contents

Page

Preface ............ ............ ............ ............ ......... v

Acknowledgments ............ ............ ............ ........... vi

Executive Summary ............ ............ ............ .......... vii

1 Introduction ............ ............ ............ ............ 1

2 Objectives ............ ............ ............ ............ . . 1

3 Current Levels of Unmet Need ............ ............ ......... 1

Asia ............ ............ ............ ............ . . 1

Near East and North Africa ............ ............ ........ 6

Latin America and the Caribbean ............ ............ ... 6

Sub-Saharan Africa ............ ............ ............ . . 6

4 Trends in Unmet Need ............ ............ ............ .... 7

4.1 Trends in Unmet Need by Level of Education ............ . . 7

5 Unmet Need among Past Users and Future Users ............ ...... 17

5.1 Never-Users Who Do Not Intend to Use ............ ..... 17

5.3 Never-Users Who Intend to Use ............ ........... 22

5.4 Past Users Who Do Not Intend to Use ............ ...... 22

6 Unmet Need among Never-Married Women ............ .......... 22

6.1 Exposure, Contraceptive Use, and Attitude

toward Pregnancy ............ ............ .......... 23

6.2 Unmet Need ............ ............ ............ ... 23

7 Trends in Contraceptive Use among Never-Married Women ......... 28

8 Trends in Unmet Need among Never-Married Women ............ . . 29

9 Reasons for Nonuse among Women with Unmet Need ............ . . 30

10 Conclusion ............ ............ ............ ............ 31

References ............ ............ ............ ............ ..... 33
iv
v

Preface

One of the most significant contributions of the MEASURE DHS+ program

is the creation of an internationally comparable body of data on the demographic

and health characteristics of populations in developing countries. The DHS

Analytical Studies series and the DHS Comparative Reports series examine these

data, focusing on specific topics. The principal objectives of both series are: to

provide information for policy formulation at the international level, and to examine

individual country resultsin an international context. Whereas Comparative Reports

are primarily descriptive, Analytical Studies take a more analytical approach. 

The Analytical Studies series comprises in-depth, focused studies on a variety

of substantive topics. The studies are based on a variable number of data sets,

depending on the topic under study. A range of methodologies is used, including

multivariate statistical techniques. The topics covered are selected by MEASURE

DHS+ staff in conjunction with the MEASURE DHS+ Scientific Advisory Committee and USAID.

It is anticipated that the Analytical Studies will enhance the understanding of

significant issues in the fields of international population and health for analysts and

policymakers.

Martin Vaessen

Project Director
Acknowledgments 

The author would like to thank Luis Ochoa for a review of the manuscript, 

Judi Miller of the Office of Population Research, Princeton University for 

Secretarial assistance, Yonas Beka and Albert Themme for programming help, and 

Sidney Moore for editing.
vii

Executive Summary

This report is a review of the extent of unmet need for family planning in

55 developing countries. Estimates are based on data from Demographic and

Health Surveys (DHS) carried out in the last decade of the twentieth century. In 33

of the countries, more than one survey has been conducted, which permits the

assessment of recent trends in unmet need. Levels and trends of unmet need among

never-married women are documented for 14 of the 22 sub-Saharan countries. The

report also extends the analysis of unmet need by disaggregating it by whether

contraception was used in the past and by whether there is an intention to use a

method in the future.

The total demand for family planning (the sum of current contraceptive

prevalence and unmet need) averages 70 percent in Asia, Latin America, and North

Africa and 44 percent in sub-Saharan Africa. In the first three, unmet need includes

about one-third of women in Cambodia, Nepal, Pakistan, and Yemen and reaches

its highest level (40 percent) in Haiti. The lowest levels of unmet need (6 to 7

percent) are evident in Vietnam, Colombia, and Brazil. The overall demand for

family planning outside sub-Saharan Africa is for limiting rather than for spacing

of births. In contrast, the demand in sub-Saharan Africa is primarily for birth

spacing. (Kenya and South Africa are exceptions.) Unmet need in general is highest

in Senegal, Togo, Comoros, Rwanda, and Uganda.

An analysis of the reasons for nonuse among women classified with an

unmet need for family planning indicates that perceived lack of exposure to the risk

of pregnancy is the principal explanation, followed by method-related problems and

opposition to the practice of contraception.

Declines in unmet need are clearly evident in 23 of the 33 countries that had

more than one DHS survey. In sub-Saharan Africa, the declines are found among

women with some education, but in other regions, declines are also found among

women with no formal education. Despite the declines, unmet need for family

planning remains at significant levels for most of the countries included in this

review and thus continues to be important for population and reproductive health

policy.
1

1 Introduction

The main rationale for the study of unmet need is to estimate the potential unsatisfied demand for

family planning (Casterline and Sinding, 2000). The measurement of unmet need has undergone various

modifications although the fundamental concept has remained unchanged (Westoff and Ochoa, 1991; United

Nations, 2000). In its basic form, the objective is to identify women who are currently exposed to the risk

of unintended pregnancy but who are not using any method of contraception. In theory, these women either

do not want any more births or want to postpone the next birth at least two more years—classified

respectively as having an unmet need for limiting or an unmet need for spacing. Many expansions of this

basic concept have been suggested over the years, for example, to take into account only modern method use,

to include various health dimensions, and to include unmarried women, as well as various other refinements

(Dixon-Mueller and Germain, 1992). The original measure of unmet need is used here partly for consistency

and comparability with earlier work but also because the measure has held up well. We have continued the

emphasis on currently married women but have also included estimates of unmet need for never-married

women in sub-Saharan Africa. These estimates are based on an algorithm developed in the last DHS

comparative report on unmet need (Westoff and Bankole, 1995).

2 Objectives

The objectives of this report on unmet need are threefold:

• To present a comparative picture of current unmet need and the demand for family planning in the

developing world at the end of the century

• To evaluate recent trends in unmet need in countries that have conducted more than one DHS survey

• To extend the comparative analysis of unmet need to include the dimensions of past use of

contraception and intention to use a method in the future.

The surveys included in this review are primarily those conducted after completion of the first phase

of the Demographic and Health Surveys program (DHS-I). This is partly because the standard measure of

unmet need was not developed until the second phase of the DHS program (DHS-II) in the early 1990s but

also because the focus is on the most recent data on unmet need. In the section on trends, we have

incorporated some estimates from DHS-I for countries that later conducted another DHS survey.

3 Current Levels of Unmet Need

Estimates of unmet need and current use of contraception (contraceptive prevalence) are shown in

Table 3.1 for 55 countries that conducted DHS surveys in the 1990s, mostly in the last half of the decade.

For each country, the two measures are shown both for spacing and for limiting. The total demand for family

planning (Figure 3.1), defined as the sum of unmet need and contraceptive prevalence, is shown for both

spacing and limiting components in Table 3.1. The ratio of prevalence to demand is the percentage of

demand satisfied.

Asia

Unmet need in the 12 Asian countries ranges from a low of 6.9 percent in Vietnam to a high of

31.4 percent in Nepal, 31.8 percent in Pakistan, and 32.6 percent in Cambodia. It is important to understand

that contraceptive prevalence is rising rapidly in most of the countries of the developing world and that for

Pakistan in particular, the estimates are nearly ten years old. A more recent survey in Pakistan conducted

in 1994-1995 (Population Council, Ministry of Population Welfare, and United Nations Population Fund,

1998) showed an increase in contraceptive prevalence to 18.2 percent from the 11.8 percent estimated in
2

Table 3.1 Demand for family planning and its components for currently married women in 55 developing countries, based on the most recent DHS survey

in each country, 1990-2000

Country

Unmet need Current use of contraception Demand for family planning1

Percentage

of total 

demand

satisfied

Survey 

date Total Spacing Limiting Total Spacing Limiting Total Spacing Limiting

ASIA

 Bangladesh 1999-2000 15.3 8.0 7.3 53.8 15.6 38.1 70.8 24.7 46.1 78.3

 Cambodia 2000 32.6 17.4 15.2 23.8 9.4 14.4 56.4 26.8 29.6 42.2

 India 1998-1999 15.8 8.3 7.5 48.2 3.5 44.7 64.0 11.8 52.2 75.3

 Indonesia 1997 9.2 4.2 4.9 57.4 25.2 32.2 67.4 30.0 37.4 86.4

 Kazakhstan 1999 8.7 3.6 5.1 66.1 23.0 43.0 75.2 26.9 48.3 88.5

 Kyrgyz Republic 1997 11.6 4.5 7.2 59.5 26.3 33.3 71.2 30.7 40.5 83.6

 Nepal 1996 31.4 14.3 17.1 28.5 2.6 25.9 59.9 16.9 43.0 47.6

 Pakistan 1990-1991 31.8 16.3 15.4 11.8 2.1 9.8 43.6 18.4 25.2 27.2

 Philippines 1998 18.8 8.2 10.6 47.8 13.1 34.7 69.5 23.6 45.9 73.0

 Turkmenistan 2000 10.1 5.2 4.9 61.8 22.0 39.8 72.2 27.5 44.7 86.0

 Uzbekistan 1996 13.7 6.6 7.0 55.6 20.2 35.4 69.3 26.8 42.4 80.3

 Vietnam 1997 6.9 3.5 3.5 75.3 14.8 60.5 83.0 18.6 64.4 91.6

NEAR EAST/NORTH AFRICA

 Armenia 2000 11.3 2.1 9.3 60.5 11.8 48.7 73.1 14.6 58.5 84.5

 Egypt 2000 11.2 3.6 7.6 56.1 11.4 44.7 68.2 15.4 52.9 83.6

 Jordan 1997 14.2 7.4 6.8 52.6 18.2 34.3 71.3 28.9 42.3 80.1

 Morocco 1995 16.1 6.3 9.8 50.3 17.2 33.1 69.4 25.1 44.3 76.8

 Turkey 1998 10.1 3.8 6.3 63.9 14.3 49.6 75.6 19.0 56.6 86.6

 Yemen 1997 38.6 17.2 21.4 20.8 7.2 13.6 59.4 24.4 35.0 35.0

LATIN AMERICA/CARIBBEAN

 Bolivia 1998 26.1 6.8 19.3 48.3 13.3 35.0 74.4 20.1 54.3 65.0

 Brazil 1996 7.3 2.6 4.7 76.7 14.0 62.8 85.8 17.6 68.3 91.5

 Colom bia 2000 6.2 2.7 3.5 76.9 18.4 58.6 86.3 22.9 63.3 92.8

 Dominican Rep. 1999 11.8 7.4 4.4 69.5 17.7 51.7 82.6 26.3 56.3 85.7

 Guatemala 1998-1999 23.1 11.8 11.3 38.2 8.5 29.7 62.2 21.0 41.2 62.9

 Haiti 2000 39.8 16.0 23.8 28.1 9.8 18.3 67.8 25.7 42.1 41.4

 Nicaragua 1997-1998 14.7 6.3 8.4 60.3 15.9 44.4 76.4 23.2 53.2 80.7

 Paraguay 1990-1991 15.0 8.8 6.2 48.4 23.6 24.8 66.3 35.0 31.3 77.4

 Peru 2000 10.2 3.6 6.7 68.9 20.3 48.5 82.5 25.7 56.8 87.6

WEST AFRICA

 Benin 1996 25.7 17.2 8.6 16.4 11.3 5.1 42.1 28.5 13.7 38.9

 Burkina Faso 1998-1999 25.8 19.0 6.8 11.9 9.0 2.8 37.7 28.0 9.7 31.5

 Cameroon 1998 19.7 13.3 6.4 19.3 12.1 7.3 39.1 25.4 13.7 49.5

 Central African Rep. 1994-1995 16.2 11.6 4.6 14.8 11.9 2.9 31.0 23.5 7.5 47.7

 Côte d’Ivoire 1998-1999 27.7 20.0 7.6 15.0 10.0 5.0 42.7 30.1 12.6 35.2

 Gabon 2000 28.0 19.9 8.0 32.7 24.0 8.7 60.7 43.9 16.8 53.9

 Ghana 1998 23.0 11.2 11.8 22.0 12.3 9.7 45.0 23.5 21.5 48.8

 Guinea 1999 24.2 16.0 8.2 6.2 3.6 2.6 30.4 19.6 10.8 20.5

 Mali 1995-1996 25.7 20.1 5.7 6.7 4.3 2.5 32.5 24.3 8.1 20.7

 Niger 1998 16.6 14.0 2.7 8.2 6.9 1.3 24.9 20.9 4.0 33.0

 Nigeria 1999 17.5 12.9 4.6 15.3 9.1 6.2 32.8 22.0 10.8 46.7

 Senegal 1997 34.8 25.5 9.4 12.9 8.0 4.9 47.8 33.5 14.3 27.1

 Tchad 1996-1997 9.7 6.6 3.1 4.1 3.1 1.0 13.8 9.7 4.1 30.0

 Togo 1998 32.3 21.4 10.9 23.5 14.6 8.9 55.8 36.0 19.8 42.1

EAST AND SOUTHERN AFRICA

 Comoros 1996 34.6 21.8 12.9 21.0 11.8 9.2 55.6 33.6 22.0 37.7

 Eritrea 1995 27.5 21.4 6.1 8.0 5.7 2.2 35.4 27.1 8.3 22.4

 Ethiopia 2000 23.1 14.1 9.0 5.9 2.8 3.1 29.0 16.9 12.1 20.4

 Kenya 1998 23.9 14.0 9.9 39.0 13.4 25.6 64.8 28.9 35.9 63.2

 Madagascar 1997 25.6 14.1 11.4 19.4 7.9 11.6 45.0 22.0 23.0 43.2

 Malawi 2000 29.7 17.2 12.5 30.6 12.7 17.9 60.3 29.9 30.4 50.8

 Mozambique 1997 6.7 5.3 1.5 7.3 4.4 2.8 14.0 9.7 4.3 51.9

 Namibia 1992 21.9 14.9 6.9 28.9 11.2 17.7 50.7 26.1 24.6 56.9

 Rwanda 2000 35.6 24.0 11.6 13.2 7.3 5.9 48.8 31.3 17.5 27.1

 South Africa 1998 15.0 4.7 10.3 56.3 14.4 41.8 71.2 19.1 52.1 79.0

 Tanzania 1999 21.8 13.8 8.0 25.4 15.1 10.3 47.2 28.9 18.3 53.7

 Uganda 2000 34.6 20.7 13.9 22.8 11.2 11.6 57.3 31.9 25.5 39.7

 Zambia 1996-1997 26.5 18.7 7.8 25.9 15.8 10.0 52.4 34.5 17.9 49.4

 Zimbabwe 1999 12.9 7.3 5.6 53.5 29.4 24.1 68.2 38.0 30.2 81.0

1

 "Total demand" includes pregnant or amenorrheic women who became pregnant while using a method. In most of the sub-Saharan countries, this

 information was not collected.
3

Figure 3.1 Demand for family planning in 55 developing countries,

Demographic and Health Surveys, 1991-2000
4

Figure 3.1—Continued
5

Figure 3.1—Continued

1990-1991. It is undoubtedly higher now. Although there may be some differences in measurement in the

two surveys, unmet need in Pakistan also increased (to 36.7 percent), which might be expected if the increase

in demand for fertility regulation exceeded the availability of acceptable contraception. The percentage of

demand satisfied estimated from the Pakistan DHS survey was only 27 percent. The highest level was in

Colombia at 93 percent, which was paralleled only by Vietnam and Brazil among the countries included in

this review.

There is a striking similarity between India and Bangladesh in these measures. Both countries show

the same level of unmet need and close to the same level of contraceptive prevalence with the result that both

have a similar proportion of total demand satisfied. The one difference is that India with its heavy reliance

on sterilization (36 percent compared with 9 percent in Bangladesh) shows more contraceptive use for

limiting purposes. The central Asian countries, also show similar overall rates; the total demand for family

planning in these countries ranges from 69 to 75 percent. Contraceptive use and the demand for limiting

exceed the demand for spacing in all of the Asian countries although unmet need for spacing is about the

same magnitude as that for limiting.

Near East and North Africa

There are six countries in this geographic grouping in which DHS surveys have been completed

(Table 3.1). Yemen, with 38.6 percent in the total unmet need category, is a conspicuous outlier.

Contraceptive prevalence in Yemen is 20.8 percent, and the total demand satisfied is only 35 percent. At the

opposite extreme is Turkey, which is partly in Europe, with an unmet need of 10.1 percent and with 86.6

percent of its total demand for family planning satisfied. According to the latest survey in Egypt in 2000 and

a new survey in Armenia, unmet need in those countries is now at a level similar to Turkey. Unmet need and

contraceptive prevalence are similar in Morocco and in Jordan. In all six countries, the demand for limiting

births is significantly higher than the demand for spacing.
6

Latin America and the Caribbean

In the year 2000, Haiti showed the highest level of unmet need among all 55 countries in this

review—just below 40 percent. Only 41 percent of total demand for family planning in Haiti was satisfied.

Although less extreme, Bolivia and Guatemala also show high levels of unmet need—26.1 and 23.1 percent,

respectively, with slightly less than two-thirds of their total demand satisfied. The Dominican Republic and

Peru have similar percentages in the various categories. Brazil and Colombia are the furthest along in the

fertility transition and show the lowest unmet need and the highest proportion of demand satisfied in the

group. Contraceptive prevalence is comparatively low in Paraguay, but it should be remembered that the

survey in that country was conducted in 1990, and there have undoubtedly been changes. As in the other

regions described above, contraceptive use for limiting births consistently exceeds use for birth spacing. This

pattern is not consistent for unmet need, however.

Sub-Saharan Africa

There are 28 countries in this region, equally divided between West Africa and southern and East

Africa, that completed at least one DHS survey in the 1990s. The two regions are very different in terms of

contraceptive prevalence and overall demand for family planning. In West Africa, only 3 countries—Gabon,

Ghana, and Togo—show contraceptive prevalence over 20 percent, while in southern and East Africa 9 of

14 countries exceed this level. In West Africa, only Gabon and Togo have a total demand exceeding

50 percent, with Senegal close to this level; in southern and East Africa, 8 countries fall in this category. The

percentage of demand satisfied ranges from a low of about 20 percent in Guinea and Mali to a high of about

80 percent in South Africa and Zimbabwe.

Unmet need is highest, reaching approximately one-third of all married women, in five countries:

Senegal, Togo, Comoros, Rwanda, and Uganda. The lowest levels are seen in Mozambique and Tchad,

countries in which the trend toward lower fertility has lagged behind the other countries and where the total

demand for family planning is only 14 percent. Low levels of unmet need are also evident in countries that

have effectively satisfied the demand for family planning, such as Zimbabwe and South Africa.

Unlike the other regions, interest in family planning in sub-Saharan Africa is focused on spacing

rather than limiting births. The total demand for spacing is greater than the demand for limiting in all but

a few of the countries. The major exceptions are South Africa, where 73 percent of demand is for limiting,

and Kenya, where the demand for limiting is 55 percent. Excluding these two countries, the average demand

for spacing comprises close to two-thirds of the total demand for family planning. Why is spacing the

dominant emphasis in sub-Saharan Africa in contrast to the rest of the developing world? Perhaps the more

fruitful way to pose this question is to ask why there is comparatively less interest in limiting births in subSaharan Africa. From this perspective, the explanation can be found in why the small-family norm has not

yet emerged in most of these countries. It is the familiar litany of differences in development, in education,

in the status of women, and in exposure to the mass media. In sub-Saharan Africa, however, concern about

maternal and child health makes women more receptive to the idea of using contraception to increase the

length of birth intervals. Organized family planning programs have been more successful in appealing to this

concern than to concerns for economic self-interest that underly the appeals of family planning programs in

other regions.

The positive health effects of prolonging birth intervals have been documented in other studies

(Bicego and Ahmad, 1996; Hobcraft, McDonald and Rutstein, 1985; Rafalimanana and Westoff, 2001). The

implications for rates of fertility are less certain (Greene, 1998). It is clear that the use of contraception to

limit family size is the main avenue to fertility decline.
1

 In a special report on unmet need in Ghana (Govindasamy and Boadi, 2000), a more liberal definition was used that

increased the unmet need for spacing from 11 to 22 percent. This difference increased the estimated total unmet need

from 23 to 33 percent and led to the conclusion that unmet need in Ghana was really unchanged over the decade. It is

clear that the unmet need for limiting has not declined; the difference relates only to the unmet need for spacing.

7

4 Trends in Unmet Need

A considerable number of countries in the DHS program have conducted more than one survey.

These data can be used for the analysis of trends in the proportion of women with an unmet need for family

planning. In this review, we include estimates from DHS-I despite some minor differences in the evolving

measure of unmet need. The trends are shown in Figure 4.1 with a separation by spacing and limiting need.

The overall trend is clearly a reduction in unmet need. When one considers the short intervals between

surveys, some of the reductions are impressive—from 16 to 9 percent in Kazakhstan in less than 5 years,

from 25 to 11 percent in Egypt in 11 years, and from 22 to 14 percent in Jordan in 7 years. In Bolivia, the

decline over 9 years was from 36 to 26 percent; in 14 years in Peru, unmet need dropped from 28 to

10 percent. In sub-Saharan Africa, the greatest declines were in Ghana, with a decline from 35 to 23 percent

in 10 years (all of the decline was in the need for spacing component);1 in Kenya, with a decline from 38 to

24 percent in 10 years; and in Zimbabwe, with a drop from 22 to 9 percent in 10 years. The trend in most

of the remaining countries is in the same direction although less dramatic. In Guinea, Mali, Senegal, and

Uganda, however, there is no indication yet of a reduction in unmet need, and in several other sub-Saharan

African countries, only slight reductions are evident so far. In most of the countries with declines in unmet

need, the trend is seen for both the limiting and the spacing components. It is important to recognize that the

evidence for these declines in sub-Saharan Africa is only from the last decade. In an earlier study of such

trends that also included estimates of unmet need (for limiting births) from the 1980s with a few surveys

included from the 1970s based on World Fertility Survey data, sharp increases in unmet need were observed

in contrast to other regions of the world. The observation then was that “unmet need is a moving target rising

in the early stages of the fertility transition as interest in family limitation grows and declining in the later

stages when family planning is adopted” (Westoff and Bankole, 2000). However, even though the proportion

of women with an unmet need for family planning is diminishing, the continuing population increase can

significantly offset the relative decline.

4.1 Trends in Unmet Need by Level of Education

It is important to determine whether the general decline in unmet need is uniform across educational

categories (Figure 4.2). Since the adoption of family planning has typically been led by the more educated

population, it is particularly important to monitor trends in the less educated segments.
Figure 4.1 Trends in unmet need for family planning among currently married women,

Demographic and Health Surveys, 1986-2000
Figure 4.1—Continued
Figure 4.1—Continued
Figure 4.1—Continued
12

Figure 4.2 Trends in unmet need for family planning (percent)

among currently married women by level of education,

Demographic and Health Surveys, 1986-2000
13

Figure 4.2—Continued
14

Figure 4.2—Continued
15

Figure 4.2—Continued
16

Figure 4.2—Continued
2

 Not all of the countries or all of the most recent surveys in Table 3.1 are represented in this analysis because of data

access problems at the time this work was completed.

17

In the Asia and Near East/North Africa region, with the exception of Bangladesh and India, where

there has been little recent change (the interval between surveys in Bangladesh is only three years), and

Turkey, which had already reached a low level of unmet need in populations with some education, the

downward trend is evident in all three educational categories. Although unmet need remains highest among

women with no formal education and lowest among those with secondary and higher education, there are

strong indications that this educational differential will disappear in the foreseeable future.

The general picture is the same in the Latin America/Caribbean region. The most dramatic declines

in unmet need are in Brazil, where among women with no education, the level of unmet need dropped from

30 to 6 percent between 1986 and 1996. In 1996, unmet need among Brazilian women with primary or

secondary and higher education was only 2 percent. Given that less than 7 percent of Brazilian women

reported no education in 1996, the overall amount of unmet need in that country must be approaching zero.

Among other countries in the region, the educational differential in unmet need still persists. In Peru, unmet

need between 1986 and 1996 was cut in half at all three educational levels. In Colombia, unmet need among

women with no education declined from 22 percent in 1986 to 10 percent in 2000. The proportions have also

been cut in half in the other two educational groupings. In contrast, unmet need among women with less than

a secondary education remains at a very high level in Bolivia, Guatemala, and Haiti. In Haiti, unmet need

is high (33 percent) even among women with more than a primary education, although it has declined from

40 percent in 1994.

With several exceptions, the decline of unmet need in sub-Saharan Africa has occurred mainly

among the minority of women with some formal schooling. Côte d’Ivoire, Ghana, Togo, Kenya, Rwanda,

Zambia, and Zimbabwe are the main exceptions where declines in unmet need are also evident in the

uneducated segment of the population. In general, the strong educational differential apparent in Asia and

Latin America has not yet emerged in most of the sub-Saharan countries included here.

5 Unmet Need among Past Users and Future Users

Not all unmet need is the same. There is the important distinction between unmet need for spacing

and unmet need for limiting births. The latter is clearly more serious both for the woman who is exposed

to the risk of an unwanted birth and for the level of fertility itself. In addition to the spacing/limiting

dimension, nonusers in need of family planning can also be distinguished by their past experience with

contraception and by their intention to use a contraceptive method in the future. A study based on women

interviewed in the Morocco DHS survey in 1992 and reinterviewed in 1995 demonstrates that information

on these two indicators is highly predictive of subsequent family planning behavior (Curtis and Westoff,

1996). Of Moroccan women with an unmet need in 1992 who had never used a method and who did not

intend to use one in the future, 22 percent reported using a method in the following three years. At the

opposite extreme, 77 percent of those who had used a method and who intended to resume use actually

became users in the intervening three years. In the two intermediate categories, 56 percent of never-users

who intended to use became users, as did 62 percent of past users who did not intend to use.

5.1 Never-Users Who Do Not Intend to Use

Of these four possible combinations of past use and intention to use, the most challenging segment

of unmet need is for the group of women who have never used contraception and who report that they have

no intention to use it in the future. If the Moroccan experience is at all representative of the rest of the world,

some of these women—about one-quarter—will change their mind and become users, but the category is

clearly the most difficult from a program point of view. There are dramatic variations across countries2 in
18

the proportion of women with this kind of unmet need (column one Table 5.1). The countries with the

highest proportions of unmet need of this type, about 50 percent or greater, include India, Pakistan, Egypt,

Yemen, Guatemala, Eritrea, Mozambique, Niger, and Tchad. The countries with the lowest proportions,

under 10 percent, are Kazakhstan, the Kyrgyz Republic, Morocco, Brazil, and Colombia. For the most part

(Egypt and Morocco are exceptions), the same patterns are evident for the composition of unmet need for

limiting as for total unmet need (not shown). In general, countries with large concentrations of unmet need

from never-users who do not intend to use are those with the highest overall levels of unmet need and those

that rank among the least developed nations. The average proportion in this subcategory of unmet need is

31 percent for the sub-Saharan countries, 22 percent for the Latin American countries, and 30 percent for

the Asian countries and other regions.

These women with an unmet need who have never used contraception and do not intend to use any

method not only potentially require contraceptive information and supplies but also pose a difficult

motivational challenge for program planners. How do these women differ from women in the other

categories of unmet need? What are their principal reasons for not intending to use a method despite their

exposure to the risk of an unintended pregnancy?

Women in this subcategory of unmet need are most likely to live in rural areas and are clearly the

least educated of the four categories. They have the highest ideal number of children and the lowest

proportion of women reporting their last birth as unwanted. They are also the least likely to have been

exposed to family planning messages on radio or television. 

For all women classified in the unmet need category who reported that they did not intend to use a

method in the future, the main reason for this attitude was probed in the interview. For the women in subSaharan Africa who had never used a method in the past, the principal reason for not intending future use

was opposition to the use of contraception, which includes religious reasons for some and husband’s

opposition for others as well as the woman’s own feelings. For 25 countries in this region, various forms

of opposition to use collectively averaged 30 percent of the reasons for not intending to use. The other major

reasons were wanting more children (an average of 26 percent) and lack of knowledge of methods or where

to obtain them (an average of 18 percent). There is enormous variation across countries in which reasons

are cited; for example, lack of knowledge ranges from less than 1 percent in Comoros to nearly 40 percent

in Tchad. Other countries with high proportions reporting ignorance of methods or sources are Burkina Faso,

Cameroon, Madagascar, Eritrea, and Uganda (Ethiopia would probably fall in this category, but the data were

not yet available). Similarly, opposition to the idea of contraception ranges from 5 percent in Malawi to

57 percent in Zimbabwe among women in this subcategory of unmet need. Other reasons for not intending

future use were much lower. Fear of side effects appeared in a few countries—Haiti with the highest

(35 percent) with Comoros, Ghana, and Kenya recording about 20 percent—but considerations of cost,

convenience, or health were negligible in sub-Saharan Africa. Lack of exposure to risk (infrequent sex or

problems of infecundity) accounted for an average of 7 percent of the responses.

In the other region, various forms of opposition to contraceptive use are the principal reason for not

intending to use among women with unmet need who have never used a method. In most countries except

Bolivia, Guatemala, and Peru, ignorance of contraception is a minor reason for not using family planning,

and as in Africa, cost and convenience seem not to be important explanations for intended nonuse. In India,

wanting more children dominates, including specific references to having a son. Fear of side effects appears

in a few countries as a moderately important reason.

Regardless of the reasons for not intending to use a method, the evidence indicates that the

percentage of women in this category is declining over time. Figure 5.1 shows that the proportion of

currently married women who are classified in the unmet need category and who have never used

contraception and who do not intend to use a method in the future is declining in all but two of the 22

countries in which this trend is reviewed (Bolivia and Burkina Faso).
19

Table 5.1 Past use and intention to use a contraceptive method, among currently married women with an unmet need for family

planning, Demographic and Health Surveys, 1990-1999

Country

Women with unmet need for family planning

Never used Used in the past

Survey 

date 

Does not

intend to use

Intends 

to use

Does not

intend to use

Intends 

to use Total

ASIA

 Bangladesh 1996-1997 10.8 31.2 8.0 50.0 100.0

 India 1992-1993 53.7 29.9 7.8 8.5 100.0

 Indonesia 1997 26.7 16.7 26.4 30.2 100.0

 Kazakhstan 1999 8.5 12.4 26.6 52.4 100.0

 Kyrgyz Rep. 1997 2.3 21.5 29.2 47.0 100.0

 Nepal 1996 19.8 58.2 4.7 17.3 100.0

 Pakistan 1990-1991 65.3 16.8 8.7 9.1 100.0

 Philippines 1998 31.1 22.5 16.6 29.8 100.0

 Uzbekistan 1996 34.9 22.8 20.9 21.4 100.0

NEAR EAST/NORTH AFRICA

 Egypt 1995-1996 49.7 39.1 4.7 6.5 100.0

 Jordan 1997 10.9 25.6 14.4 49.1 100.0

 Morocco 1992 3.0 20.9 14.8 34.3 100.0

 Turkey 1998 16.4 25.1 17.7 40.8 100.0

 Yemen 1997 53.3 16.0 14.9 15.7 100.0

LATIN AMERICA/CARIBBEAN

 Bolivia 1998 33.2 27.0 9.8 30.1 100.0

 Brazil 1996 8.1 16.6 15.8 59.6 100.0

 Colombia 1995 6.8 21.9 9.5 61.8 100.0

 Dominican Rep. 1996 10.8 23.2 12.6 53.4 100.0

 Guatemala 1999 48.2 29.1 5.3 17.4 100.0

 Haiti 1994-1995 17.5 35.6 15.1 31.8 100.0

 Nicaragua 1997-1998 17.1 30.1 10.1 42.7 100.0

 Paraguay 1990 38.3 22.4 13.2 26.2 100.0

 Peru 1996 19.7 32.1 10.1 38.1 100.0

SUB-SAHARAN AFRICA

 Benin 1996 25.1 35.9 10.0 29.0 100.0

 Burkina Faso 1998-1999 33.2 47.9 4.0 15.0 100.0

 Cameroon 1998 33.0 21.0 10.9 35.1 100.0

 Central African Rep. 1994-1995 14.9 41.9 8.2 35.0 100.0

 Comoros 1996 30.4 30.0 11.3 28.3 100.0

 Côte d’Ivoire 1994 32.0 35.5 7.3 25.2 100.0

 Eritrea 1995 49.7 39.1 4.7 6.5 100.0

 Ghana 1998 27.2 27.1 14.8 30.8 100.0

 Guinea 1999 35.4 50.9 2.7 11.0 100.0

 Kenya 1998 14.7 41.8 6.8 36.7 100.0

 Madagascar 1997 29.0 51.3 6.6 13.1 100.0

 Malawi 1992 19.1 40.1 9.4 31.4 100.0

 Mali 1995-1996 35.6 46.8 3.6 14.1 100.0

 Mozambique 1997 49.6 34.4 4.8 11.2 100.0

 Namibia 1992 37.0 18.7 16.5 27.8 100.0

 Niger 1998 47.8 29.0 7.9 15.4 100.0

 Nigeria 1999 52.4 21.0 11.1 15.5 100.0

 Rwanda 1992 17.2 49.2 5.1 28.6 100.0

 Senegal 1997 40.4 38.6 4.7 16.2 100.0

 Tanzania 1996 27.2 42.8 6.9 23.1 100.0

 Tchad 1996-1997 62.1 29.4 4.3 4.2 100.0

 Togo 1998 13.7 23.1 17.7 45.5 100.0

 Uganda 1995 18.6 49.8 5.8 25.8 100.0

 Zambia 1996-1997 9.5 33.8 9.3 47.4 100.0

 Zimbabwe 1999 12.0 13.9 14.0 60.1 100.0
20

Figure 5.1 Trends in the percentage of currently married women with unmet

need for family planning who have never used and who do not intend to use

a contraceptive method, Demographic and Health Surveys, 1990-2000
21

Figure 5.1—Continued

5.2 Past Users Who Intend to Resume Use

If women in need of family planning who have never used a contraceptive method and who do not

intend to use a method are the most difficult group to serve, those who have used contraception in the past and

who intend to resume use are presumably the easiest to serve. Some of these women are (unintentionally)

pregnant or amenorrheic after such a pregnancy (about 40 percent for example in the 1998 Kenya DHS survey);

others may simply not have resumed use after discontinuation of use for some reason or another, primarily

because of health concerns or side effects of the method. Perhaps half of the women in this subcategory of

unmet need are not actually at risk of pregnancy at any given time, but the other half appears to be taking that

chance. The average proportion of women in this category is large, especially outside sub-Saharan Africa. In

the Latin American and Caribbean cluster, the average is 40 percent; in Asia, the Near East, and North Africa,

the average is 29 percent. In sub-Saharan Africa, on the other hand, it is lower (25 percent), probably because

the proportions of women who never used a method dominates the composition of unmet need.

The women in this category of unmet need are the most educated and, like other past users, tend to live

in cities. These women are most likely to have watched television (also shared with other past users) and to

have been exposed to media messages about family planning. They show the highest proportion currently

pregnant but have the lowest ideal number of children. About half of all women in need who intend to use a

method in the future are either pregnant or amenorrheic. The reason that they are classified in need, of course,

is that they became unintentionally pregnant and show the highest proportions with an unwanted last birth.
3

 Some sub-Saharan countries are excluded because the data were not available.

22

5.3 Never-Users Who Intend to Use

Although past users who intend to resume use are presumably the most likely to leave the unmet need

category, women who report that they intend to use but have never had any experience with contraception are

an important group. These are women who appear to already be motivated, and whose primary need is family

planning services. There are, however, a variety of more complex obstacles to contraceptive use. In the 1998

Kenya survey, the reasons for not using a method in this subcategory of unmet need include several other

considerations. A quarter of these women cite opposition to the idea particularly from their husband; another

quarter say they are not using because of health concerns or side effects. Nearly 20 percent are not exposed

to the risk of pregnancy mainly because of low fecundability, and another 15 percent say that they are not using

a method because they want more children (a response that raises some doubt about their inclusion in the unmet

need category). The importance of these various reasons may be different in other countries, but the Kenya

illustration suggests that the key to changing the status of this particular subgroup of women goes beyond

simply providing contraceptive supplies and services.

The average proportion of these women is greatest in sub-Saharan Africa (32 percent), again because

of the preponderance of never-users in that region. In the other countries, the average is 26 percent. Higher

than average proportions of these women are either pregnant or amenorrheic. Otherwise, they do not show any

characteristics that are consistently different from those of other women with unmet need.

5.4 Past Users Who Do Not Intend to Use

This remaining subcategory of unmet need is the smallest of the four, averaging 11 percent in the Latin

American/Caribbean region, only 8 percent in sub-Saharan Africa, and 15 percent in the other countries. These

are women who have discontinued use and report that they do not intend to use again.

Women in this group are clearly the oldest of any group. In all but one country, their average age (35.6

years) is the highest with a mean difference of no less than 6 years, compared with the average for all women

with unmet need (29.6 years). This suggests lower exposure to the risk of pregnancy. This group has the

highest proportion of women who say that they want no more children, an attitude clearly related to their older

age. When queried about their reasons for not intending to use a method in the future, the primary responses

were lack of exposure to the risk of pregnancy (either because of infecundity or lack of sexual activity), health

concerns, and concern about side effects. The last two reasons are especially prominent in Haiti, accounting

for two-thirds of the women.

6 Unmet Need among Never-Married Women

Unmet need is typically estimated for currently married women (as in this report). However, the

exclusion of unmarried women from such estimates has frequently been criticised. In response, Westoff and

Bankole (1995) developed an algorithm for this purpose. It is used here with slight modification. The main

focus is the population of never-married women, particularly the subset of teenagers (women age 15-19). The

challenge is the validity of responses to questions on sexual activity, a variable that is normally taken for

granted in estimates for married women. As in the 1995 analysis, the estimates are confined to women in subSaharan Africa3

 because the questions on sexual activity are not included in many countries in the other

regions. Also, in other countries, the reports on frequency of sexual intercourse—in particular the proportion

of teenagers who reveal to the interviewer that they have had sex—are implausibly low. This seems not to be

the situation in the sub-Saharan countries.
23

6.1 Exposure, Contraceptive Use, and Attitude toward Pregnancy

The proportion of never-married women who are currently using a contraceptive method is shown for

22 sub-Saharan countries (Table 6.1 for women age 15-49 and Table 6.2 for teenagers) along with exposure

to the risk of pregnancy and the planning status of a current or recent pregnancy. The data point to

considerable variation in the level of contraceptive use and exposure to risk, and they form the basis for the

later estimates of unmet need. The estimates do not simply represent the sum of percentages exposed and not

using and reporting unintended pregnancies since it is unreasonable to assume that all exposed never-married

women want to avoid pregnancy. Again, following the earlier algorithm, the procedure takes into account the

woman’s own reaction to how she would feel if she were to become pregnant in the next few weeks. The

question posed for nonpregnant women who have ever had sex is “If you became pregnant in the next few

weeks, would you be happy, unhappy, or would it not matter very much?” In estimating unmet need, only the

proportion of women who reported that they would be unhappy is used (Table 6.3). This estimate averaged

74 percent for never-married women age 15-49 and 79 percent for never-married women age 15-19. As would

be expected, these percentages are significantly lower for married women: 57 percent for teenagers and

53 percent for all married women. Thus, approximately a quarter of the never-married women, on average,

do not appear averse to the possibility of premarital fertility. 

The intercountry variation in this reaction is considerable with high indications of avoidance in

Comoros, Ghana, Guinea, Mali, Uganda, and Zimbabwe. At the opposite extreme are the Central African

Republic, Tchad, Cameroon, Mozambique, and Madagascar. It is difficult to explain these reactions. In some

instances, it may simply reflect the positive attitude most African women have about babies and the traditional

role of mother; in others, it may suggest a link between fertility and eligibility for marriage. Whatever the

explanation, the presumption that never-married women who have sex are anxious to avoid pregnancy is not

necessarily true.

The proportion of never-married women who are currently pregnant or amenorrheic after a recent

pregnancy are fairly high in some of these countries, exceeding 10 percent in the Central African Republic,

Côte d’Ivoire, Madagascar, and Mozambique, which also show the highest rates among teenagers. The

countries with the highest contraceptive prevalence are Cameroon, Côte d’Ivoire, and Togo. The familiar

higher prevalence in cities compared with that in rural areas is evident in all of the countries (Table 6.4), as

is the strong positive association with level of education. Exposure to radio and television also correlates

positively with contraceptive prevalence in all of these countries.

6.2 Unmet Need

Estimates of unmet need for each sub-Saharan country are presented in Table 6.5 for never-married

women 15-49 and never-married women 15-19. Figure 6.1 shows unmet need among never-married teenagers

(women 15-19). The basic measure reflects both the extent of contraceptive use as well as the proportion of

women who have had sex. These estimates are also adjusted downward by the proportion reporting that they

would be happy or that it would not matter if they became pregnant in the next few weeks. Two measures are

presented:

C Measure 1 includes only nonusers who have had sex in the past month; 

C Measure 2 includes these plus nonusers who reported that their last sex was more than one

month ago. 

The countries with the highest levels of unmet need among never-married women age 15-49 by both

measures of sexual activity are Côte d’Ivoire, Mali, Mozambique, Tanzania, Togo, and Zambia. The same

countries show the greatest unmet need among teenagers. The lowest levels of unmet need among nevermarried women are in Comoros, Niger, Senegal, and Tchad. These four countries are below 10 percent for

both measures and for teenagers as well as for all never-married women, primarily because of low rates of

sexual activity.
Table 6.1 Percent distribution of never-married women age 15-49 by exposure to the risk of pregnancy and the planning status of current or recent pregnancy,

Demographic and Health Surveys, 1994-1999

Pregnant or amenorrheic

Not using contraception—Had

sexual intercourse:

Country

Survey 

date 

Currently

using method Intended Unintended

In the past

 month

More than one

month ago

Never

had sex Total

Benin 1996 18.7 1.7 0.8 6.3 18.4 54.1 100.0

Burkina Faso 1998-1999 12.1 0.6 1.2 6.7 7.7 71.8 100.0

Cameroon 1998 35.9 3.3 3.5 7.9 12.6 36.9 100.0

Central African Rep. 1994-1995 12.3 8.9 3.9 13.9 14.7 46.4 100.0

Comoros 1996 4.3 0.1 0.3 1.6 3.4 90.4 100.0

Côte d’Ivoire 1994 28.2 4.7 7.2 11.8 21.2 26.9 100.0

Eritrea 1995 0.5 0.3 0.4 0.0 1.6 97.2 100.0

Ghana 1998 11.2 0.1 1.8 7.5 22.1 57.2 100.0

Guinea 1999 12.5 1.4 2.0 7.6 12.6 64.0 100.0

Kenya 1998 12.9 1.6 4.3 6.2 22.6 52.3 100.0

Madagascar 1997 10.1 8.0 2.9 10.7 16.7 51.5 100.0

Mali 1995-1996 15.1 3.7 3.9 8.1 13.3 55.9 100.0

Mozambique 1997 6.3 5.1 4.6 17.3 21.7 44.9 100.0

Niger 1998 2.4 0.7 1.4 0.6 4.3 90.6 100.0

Nigeria 1999 9.7 0.4 0.7 3.3 8.9 76.9 100.0

Senegal 1997 4.1 0.9 3.0 1.3 6.8 83.9 100.0

Tanzania 1999 12.2 3.3 2.8 13.1 16.1 52.5 100.0

Tchad 1996-1997 2.7 1.9 1.0 5.7 4.6 84.2 100.0

Togo 1998 30.8 0.5 3.2 10.0 19.9 35.6 100.0

Uganda 1995 9.6 3.9 3.7 3.8 17.1 61.9 100.0

Zambia 1996-1997 7.7 2.0 5.4 9.5 29.2 46.3 100.0

Zimbabwe 1999 7.3 1.1 2.6 2.2 12.6 74.2 100.0
Table 6.2 Percent distribution of never-married women age 15-19 by exposure to the risk of pregnancy and the planning status or current or recent pregnancy,

Demographic and Health Surveys, 1994-1999

Pregnant or amenorrheic

Not using contraception—Had 

sexual intercourse:

Country

Survey 

date 

Currently using

method Intended Unintended

In the past

month

More than one

month ago

Never had

sex Total

Benin 1996 11.6 0.9 0.8 6.3 14.1 66.3 100.0

Burkina Faso 1998-1999 8.0 0.4 0.9 6.5 6.0 78.1 100.0

Cameroon 1998 28.3 1.7 3.4 4.8 8.2 53.6 100.0

Central African Rep. 1994-1995 7.4 5.3 3.6 10.0 8.5 65.3 100.0

Comoros 1996 2.3 0.1 0.4 1.5 2.1 93.6 100.0

Côte d’Ivoire 1994 22.3 3.7 6.7 11.7 17.9 37.6 100.0

Eritrea 1995 0.0 0.0 0.2 0.0 0.4 99.4 100.0

Ghana 1998 7.0 0.2 1.2 5.3 12.5 73.9 100.0

Guinea 1999 6.9 1.2 1.4 6.4 10.6 73.5 100.0

Kenya 1998 5.7 1.1 3.7 5.7 16.1 67.6 100.0

Madagascar 1997 5.5 5.7 2.8 10.2 10.3 65.4 100.0

Mali 1995-1996 9.2 3.0 3.2 7.4 10.1 67.2 100.0

Mozambique 1997 2.6 1.9 5.0 17.3 15.6 57.6 100.0

Niger 1998 0.2 0.5 1.2 0.6 1.4 96.0 100.0

Nigeria 1999 7.5 0.6 1.3 4.0 9.0 77.6 100.0

Senegal 1997 1.4 0.8 2.6 0.7 3.0 91.5 100.0

Tanzania 1999 5.9 1.0 2.4 11.8 13.8 65.1 100.0

Tchad 1996-1997 1.7 1.4 0.8 4.6 3.7 87.8 100.0

Togo 1998 23.9 0.4 2.5 8.6 16.4 48.2 100.0

Uganda 1995 4.9 2.0 3.0 3.7 9.9 76.4 100.0

Zambia 1996-1997 4.2 1.4 4.6 8.8 23.8 57.2 100.0

Zimbabwe 1999 2.5 0.4 1.5 1.3 7.0 87.2 100.0
26

Table 6.3 Percentage of never-married and of currently married women 15-19 and 15-49 who say they would be

unhappy if they became pregnant in the next few weeks, Demographic and Health Surveys, 1994-1999

Women 15-19 Women 15-49

Country 

Survey 

date 

NevermarriedCurrently

married

NevermarriedCurrently

married

Benin 1996 82 67 69 58

Burkina Faso 1998-1999 85 51 81 63

Cameroon 1998 67 48 56 38

Central African Rep. 1994-1995 58 38 52 36

Comoros 1996 96 76 97 49

Ghana 1998 94 75 86 66

Guinea 1999 95 54 91 57

Kenya 1998 80 47 75 44

Madagascar 1997 47 28 46 41

Mali 1995-1996 90 63 89 57

Mozambique 1997 63 52 59 45

Niger 1998 89 50 88 52

Tanzania 1999 79 46 73 47

Tchad 1996-1997 57 51 56 46

Togo 1998 80 65 70 59

Uganda 1995 93 80 91 77

Zambia 1996-1997 73 61 70 59

Zimbabwe 1999 91 79 87 69

Table 6.4 Percentage of never-married women currently using a contraceptive method, by residence, education, and exposure to mass

media, Demographic and Health Surveys, 1992-1999

Residence Level of education Exposure to mass media

Country

Survey 

date Urban Rural

No

education Primary Secondary None

Radio

or TV Both

Benin 1996 23.8 11.3 6.6 22.1 37.5 u u u

Burkina Faso 1998-1999 22.1 6.8 6.1 12.8 31.6 5.8 14.6 39.0

Cameroon 1998 45.0 26.9 3.2 18.6 49.9 44.4 40.4 51.1

Central African Rep. 1994-1995 19.6 3.7 3.5 9.8 32.0 4.4 10.8 28.7

Comoros 1996 5.4 3.7 1.1 4.6 7.1 2.1 5.0 7.2

Côte d’Ivoire 1994 34.8 20.2 12.4 27.4 52.1 12.0 22.1 40.7

Eritrea 1995 0.7 0.3 0.8 0.3 0.5 0.5 0.7 0.3

Ghana 1998 14.0 8.8 5.5 5.7 13.5 5.5 9.7 14.8

Guinea 1999 17.7 5.0 5.8 8.8 30.9 3.2 15.6 22.4

Kenya 1998 20.2 10.2 18.1 10.9 16.1 10.1 13.0 16.5

Madagascar 1997 16.3 6.5 0.6 5.7 19.5 6.0 12.0 16.6

Malawi 1992 4.4 1.6 0.0 1.5 9.2 0.1 3.4 1u

Mali 1995-1996 21.7 4.8 4.6 20.9 35.3 2.6 13.7 23.6

Mozambique 1997 12.4 2.1 1.1 5.0 21.8 2.2 7.0 16.1

Namibia 1992 35.9 8.3 11.4 13.2 26.4 7.2 15.8 35.7

Niger 1998 4.2 0.5 1.3 3.3 4.0 0.9 1.2 4.0

Nigeria 1999 11.0 9.1 1.4 3.3 16.2 5.3 18.4 15.1

Rwanda 1992 4.6 1.5 1.6 1.5 2.9 u u u

Senegal 1997 5.4 1.8 1.6 5.5 6.1 u u u

Tanzania 1996 15.6 5.2 1.0 7.9 18.7 4.6 10.7 18.7

Tchad 1996-1997 7.9 0.7 0.4 2.5 16.3 0.9 5.3 17.2

Togo 1998 37.5 22.5 12.6 24.5 50.8 19.1 34.4 46.5

Uganda 1995 16.4 7.3 0.9 6.4 18.7 6.0 13.0 17.5

Zambia 1996-1997 10.4 4.4 0.8 4.6 12.2 4.8 9.1 10.2

Zimbabwe 1999 10.3 4.9 * 5.5 7.7 5.3 7.4 7.8

u = Unknown (not available)

* Too few cases to estimate a reliable rate

1 Radio only
27

Table 6.5 Unmet need for contraception among never-married women age 15-49 and never-married women age 15-19, Demographic

and Health Surveys, 1994-1999

Survey 

date 

Women 15-49 Women 15-19

Country Measure 1 Measure 2 Measure 1 Measure 2

Benin 1996 5.2 17.8 6.0 16.7

Burkina Faso 1998-1999 6.6 12.9 6.4 11.5

Cameroon 1998 7.9 15.0 6.6 12.1

Central African Rep. 1994-1995 11.1 18.8 9.4 14.3

Comoros 1996 1.8 5.1 1.8 3.8

Côte d’Ivoire11994 14.3 27.0 14.2 25.6

Ghana 1998 8.2 27.2 5.0 17.9

Guinea 1999 8.9 20.4 7.5 17.5

Kenya 1998 8.9 25.9 8.3 21.1

Madagascar 1997 7.8 15.5 7.6 12.4

Mali 1995-1996 11.1 22.9 9.9 18.9

Mozambique 1997 14.8 27.6 15.9 25.7

Niger 1998 1.9 5.7 1.7 3.0

Nigeria 1999 3.5 10.5 4.7 12.5

Senegal11997 4.0 9.2 3.1 5.4

Tanzania 1999 12.4 24.1 11.7 22.6

Tchad 1996-1997 4.2 6.8 3.4 5.5

Togo 1998 10.2 24.1 9.4 22.5

Uganda 1995 7.1 22.7 6.4 15.6

Zambia 1996-1997 12.0 32.5 11.0 28.4

Zimbabwe 1999 4.2 15.1 2.5 8.9

Note: Measure 1 is based on women who reported sex in the past month plus pregnant or amenorrheic women who reported that pregnancy

as unintended. Measure 2 includes Measure 1 and adds women who reported sex more than one month before.

1

 Survey did not include the question on attitude toward the possibility of becoming pregnant. Estimates of the proportion that would be

unhappy are determined from the proportion of pregnancies reported as unintended.
28

7 Trends in Contraceptive Use among Never-Married Women

In about half of the 14 sub-Saharan countries that have had repeat surveys, the level of contraceptive

use among sexually active never-married women has increased (Figure 7.1). Significant increases in short

periods of time are evident in Burkina Faso, Mali (possibly exaggerated by differences in the definition of

use), Tanzania, Uganda, and Zambia. The remaining nine countries show little change. It is important to

remember that the estimates depend not only on the accuracy of the reports of contraceptive use but, perhaps

more critically, on the accuracy of reports of sexual activity. There is probably less of a tendency for those

using contraception to conceal sexual activity than there is for women not using a method; the net result may

be that the level of contraceptive use may be overestimated.

Figure 7.1 Trends in the proportion currently using contraception

among never-married women age 15-49 who have ever had sex, 

sub-Saharan Africa, Demographic and Health Survey, 1987-1999
29

8 Trends in Unmet Need among Never-Married Women

Trends in unmet need for the sub-Saharan countries show a mixed pattern of change. However, if

these estimates are reliable, unmet need has declined only in Madagascar and Nigeria. The main picture

(Figure 8.1) is one of little change, although there are several countries that show some suggestion of increases

in unmet need, a plausible change that might reflect increases in exposure to the risk of pregnancy prior to

contraceptive use. Although it seems plausible to assume that such exposure is likely to increase over time,

available evidence from sub-Saharan countries indicates trends toward later age at marriage and later age at

sexual initiation.

Figure 8.1 Trends in unmet need for family planning (percent) among

never-married women age 15-49, sub-Saharan Africa, 

Demographic and Health Surveys, 1987-1999
30

9 Reasons for Nonuse among Women with Unmet Need

In the most recent version of the DHS questionnaire, a question was added to probe directly into the

reasons for nonuse among women who said that they wanted no more children or who wanted to delay the

next birth at least two more years. The question was explicitly phrased to highlight the apparent inconsistency

between intention and behavior. The relevant subset of women were asked, “You have said that you do not

want any more children, but you are not using any method to avoid pregnancy. Can you tell me why? Any

other reason?” The same kind of question was asked of women who wanted to delay the next child. A total

of 22 answer categories were precoded for the interviewer. The distribution of the responses in summary

categories is shown for currently married women with an unmet need for family planning in Table 9.1.

Women who were pregnant as well as those who were undecided about their reproductive intentions were not

asked the question and are excluded in the denominators of those in need.

Table 9.1 Reasons currently married women with unmet need for family planning are not currently using contraception,

Demographic and Health Survey, 1999-2000

Country

Survey 

date 

Not exposed to

pregnancy

Opposed

to use of

contraception

Lacks

knowledge of

method or

source for

method

Methodrelated

problem Other

ASIA

 Kazakhstan 1999 34 29 <1 30 20

 Turkmenistan 2000 29 48 1 23 8

NEAR EAST/NORTH AFRICA

 Egypt 2000 45 11 <1 33 22

LATIN AMERICA/CARIBBEAN

 Colombia 2000 65 10 2 28 10

 Haiti 2000 39 18 3 52 9

 Peru 2000 54 17 7 38 8

SUB-SAHARAN AFRICA

 Ethiopia 2000 48 30 29 26 3

 Gabon 2000 39 25 13 28 23

 Malawi 2000 52 28 3 39 2

 Rwanda 2000 43 17 15 27 9

 Tanzania 1999 52 31 7 25 22

 Uganda 2000 40 19 14 41 10

 Zimbabwe 1999 42 22 <1 35 12

Note: The percentages for each country total more than 100 percent because some women gave more than one reason for

nonuse.

The 22 reasons for nonuse have been grouped into 5 categories. The first covers different types of

presumed nonexposure to the risk of pregnancy—not having sex or having infrequent sex, menopause,

hysterectomy, women who reported that they could not get pregnant for physical reasons, those who said they

were amenorrheic after a recent birth, and those who reported breastfeeding as the reason for nonuse (the

distinction between amenorrhea and breastfeeding cannot be determined from these responses). The second

category includes opposition to the use of contraception on various grounds including husband’s attitudes,

religious prohibitions, and other nonspecified reasons. Responses coded “fatalistic” are also included in this

general category. Whether the respondent knows a method or a source from which to obtain a method is the

third category. Method-related problems such as concerns about health or side effects, lack of access, cost,
31

and inconvenience are included in this fourth category. The last category (Other) includes reasons not

assigned to the preceding categories as well as “don’t know” responses and nonresponses. It should be

recognized that these data are imprecise and subject to variability in interviewers’ coding judgment; they are

intended only to provide some rough insight into the apparent inconsistency between reproductive intentions

and contraceptive behavior.

For most of the 13 countries included in Table 9.1, the most common reason offered for not using a

method is a perceived lack of exposure to the risk of pregnancy. (It should be noted that in the operational

definition of unmet need, only amenorrheic women whose pregnancy was unintentional were included. Those

whose pregnancy had been intentional are not defined as in need and currently pregnant women, regardless

of the planning status of the pregnancy, were not asked the reason for nonuse). Between one-third and twothirds of the women in these countries reported nonexposure or little exposure as the reason they were not

using a method despite their intention to delay or avoid pregnancy. Overall, an average of 45 percent fall in

this category.

Opposition to use is a lesser but a still significant reason for nonuse. For reasons that are unclear, it

is the major reason in Turkmenistan, with 48 percent of women in the category. In general, it is slightly more

common in sub-Saharan Africa, where roughly 20 to 30 percent say they are opposed to use. Opposition

attributed to the husband is frequently cited as the reason. 

Lack of knowledge of methods or sources of supply is not an important reason for nonuse in these

countries, except in Ethiopia where it was reported by 29 percent of women in need.

On the other hand, problems with methods mainly included concerns about side effects or health, and

to a lesser extent, issues of cost and access are significant. An average of one-third of the women gave a

method-related problem as the reason for nonuse. In Haiti and in Uganda, this category of reason was

especially prominent and involved mostly concerns about side effects and health.

10 Conclusions

This report has several purposes. It is primarily devoted to summarizing recent levels of unmet need

in the 55 countries that participated in the Demographic and Health Surveys during the last decade of the

century and to describing trends in unmet need for 33 of those countries that conducted more than one survey.

In 19 of the 27 countries outside sub-Saharan Africa, the recently estimated level of unmet need for

currently married women is 15 percent or lower, while only 6 of the 28 sub-Saharan countries show a level

that low. The total demand for family planning, defined as the sum of unmet need and current use, averages

44 percent in the sub-Saharan countries in contrast to an average of 70 percent in the countries in Asia, the

Near East, and North Africa, and Latin American and the Caribbean. The percentage of total demand satisfied

is highest—exceeding 90 percent—in Vietnam, Brazil, and Colombia and lowest in Guinea, Mali, and

Ethiopia at about 20 percent. With few exceptions, the demand for family planning in sub-Saharan Africa

is primarily for spacing, which is in sharp contrast to countries in other regions where the limiting of births

is the dominant practice.

The trend in unmet need is generally downward and is apparent even over the short intervals of time

between surveys. Clear declines are evident in 23 of the 33 countries examined. These trends were also

examined by educational groupings. In sub-Saharan Africa, the reductions in need are largely confined to

women with some formal schooling; in the other regions, women with no education also participated in the

downward trend.

Unmet need has been divided not only into the two familiar components of spacing and limiting but

also by whether the woman has ever used a method in the past and by whether she intends to use one in the
32

future. These four categories have different kinds of unmet need. Women who have never used contraception

and do not intend to use are the most challenging segment of unmet need; this subcategory is most prevalent

in the least developed countries but is declining over time as a percentage of total unmet need. These women

frequently cite various kinds of opposition to the idea of contraception on their part or their husband’s part.

At the opposite extreme are those women currently in need of contraception who have used a method in the

past and who say that they intend to resume use in the future. This category is large outside sub-Saharan

Africa and includes many women who were at low risk of pregnancy at the time of the survey because of a

recent birth, but it also includes those at risk who have discontinued use for other reasons. Women in need

who have never used contraception but who intend to use are most evident in sub-Saharan Africa and would

presumably be a less complicated population to serve. The last category—women in need who have

discontinued use and do not intend to resume use—is the smallest of the four subcategories and consists

primarily of older women and women at low risk of unintended pregnancy.

In the most recent round of surveys, a question was included to determine the reasons for not using

a contraceptive method among nonusers who want either to delay the next birth or to avoid further

childbearing. The main reason was their perceived low level of exposure to the risk of pregnancy, with

method-related problems and opposition to contraceptive use also important.

The concept of unmet need should not be restricted to married women, although this has generally

been the case because of lack of data on the sexual activity of unmarried women. In some countries,

unmarried women are not included in DHS surveys, while in others, the quality of the reporting is suspect.

The most credible estimates for unmarried women appear to be for women in sub-Saharan Africa, and this

report has attempted to measure unmet need for family planning among never-married women in 22 countries

in sub-Saharan Africa. The tabulations were carried out for teenagers (women 15-19) and for women of

reproductive age (15-49) and explicitly reduce the estimates of unmet need by taking into account that about

one-quarter of the women at risk of pregnancy say that they would be happy if they were to become pregnant.

The countries with the highest levels of unmet need among never-married women are Côte d’Ivoire, Mali,

Mozambique, Tanzania, Togo, and Zambia. There has been little change in levels of unmet need in the 14

countries where trends are measurable.
33

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DHS Comparative Reports Series

1 Westoff, Charles F. 2001. Unmet Need at the End of the Century.