What Women Want? Moving Away from Unmet Need
Women in Nigeria have on average 5.7 babies, in Niger the figure is 7.3 babies and in Mexico and Sri Lanka women have 2.5 babies: Why is that the case? One of the reasons is that a lot of women (ages 15-49) use contraceptives in Mexico and Sri Lanka (71% and 68%) while very few use them in Nigeria and Niger (14% and 11%) respectively. Given these statistics people have asked if women do not use contraceptive in Nigeria and Niger because they do not perceive the need to do so or because contraceptives are simply not available. To gauge the extent to which the bottlenecks lie on the supply side (contraceptives are not available or they price is too high), an indicator is used in demographic and health survey (DHS): unmet need for family planning methods. Women with unmet need for family planning are defined by the the population division of the UN as “those who are fecund and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the birth of their next child“. Lant Pritchett points out that this definition obscures the reasons why women do not use contraceptives. And these reasons have very little to do with supply bottlenecks:
(..) DHS surveys have responses from women who do not want a child and are not using contraception about why they are not using, which includes answers like that they dislike the side effects, that they are no longer fecund, they are sexually inactive, that they have religious objections, that their husband is out of the country for a year. That is, many women give reasons suggesting they do not want contraception and only a few cite access or price as reasons for their “unmet need” status attributed to them.
On this basis a shift in the way one thinks of birth control and fertility rates is both necessary and desirable.
What women need or what women want? Every woman should be free to chose when and how many children to have: this is the point that Melinda Gates makes to justify global funding for birth control. From this perspective birth control is about women’s freedom to chose – it is about what they want and not what they need. When one looks at the problem in terms of need one tends to see the woman as a passive subject whose behavior needs to be changed by somebody else (be that her husband, the family at large or some foreign expert). As a result, the woman remains voiceless and her power to decide and chose what she wants is sidelined.
Thinking in terms of what women need has also fostered another fallacy in the approach towards reproductive health. If women need contraceptives then it is suffice to make them available and the uptake will spike, so the argument goes. Never mind if it will be confidential for women to receive these services, or how professional service providers will be or how convenient it will be for them to obtain contraceptives: if women need birth control methods, all these questions are not relevant. Yet the answers to these questions account for why the demand for family planning methods does not translate into utilization of methods of contraception.
Delivering quality birth control. Take the examples of women who are contract employees in factories in Nairobi. They work Monday to Saturday and their most likely option to obtain any family planning methods are free government health clinics. There is a problem though: these clinics are closed on Sunday. The other option available is private clinics, which they cannot afford, so these women are forced to take a day off at work to seek these services. Unsurprisingly this represents a barriers to family planning uptake. Now take the other examples of young university students in Nairobi who want to use contraceptives. They do not have time constraints therefore they could theoretically use free government health clinics. There is another barrier though: in a societies like Kenya if you are a girl you are not expected to have sex before marriage. If you then go to the government health clinics the nurse or the doctor are likely to tell you off or to judge your sexual habits. So what do you do? You just do not bother to go. A social enterprise in Nairobi called PendaHealth decided to ask the question what women want instead of what women need. If the answer to the second question is just family planning methods the answer to the first question has to with where, how and when family planning methods can be accessed. These questions create a feedback loop between service provider and service user so that the first is always interested in what the former thinks or demands.
For a long time the international health community has paid attention to the number of women who are sexually active and do not desire to have children for a while or forever. On this basis the unmet need for contraception was calculated for every country. This indicator however conceals why women chose not to take contraceptive and therefore it induces policymakers into believing that how, when and where family planning methods are accessible does not matter. Assuming that the need is already there, service providers never bothered to ask how best the demand can be accommodated. Asking what women want is fundamental if women who want to use contraceptives are to translate this will into practice.
This post draws on Penda Health’s work and research in Nairobi