UNMET NEED FOR FAMILY PLANNING; GLOBAL AND NATIONAL TRENDS AND CHALLENGES

The unmet need for Family Planning (FP) is defined as the percentage of all fecund women who are married or living in union and thus are presumed to be sexually active but not using any form of contraception, either do not want to have any more children or want to postpone their next birth for at least two more years or do not know when or if they want another child 1 . Unmet Need for modern methods includes all in the unmet need group and those who are using natural and traditional methods at the time of survey 10


Introduction
The unmet need for Family Planning (FP) is defined as the percentage of all fecund women who are married or living in union and thus are presumed to be sexually active but not using any form of contraception, either do not want to have any more children or want to postpone their next birth for at least two more years or do not know when or if they want another child 1 . Unmet Need for modern methods includes all in the unmet need group and those who are using natural and traditional methods at the time of survey 10 This unmet need may be either for limiting where a woman never wants a child; or for spacing where she wants a child only after 2 years or is not sure whether or when to have the next child 11 . Thus, unmet need is a disconnection between the women's fertility preferences and what they do about them, indicating the failure to take necessary action to prevent conception. The concept of unmet need for FP is usually applied to married women but

UNMET NEED FOR FAMILY PLANNING; GLOBAL AND NATIONAL TRENDS AND CHALLENGES
can also be applied to sexually active unmarried females and to men as well 12,13 .

Evolution of the concept of unmet need for family planning
The term was first described as "KAP-gap" reflecting the source of data because the gap between the need and the use of FP was first identified from surveys on Knowledge, Attitudes and Practices 14 .The term "unmet need" was first used by Stokes in 1977 15 .
According to the standard definition of unmet need, a woman is considered to have unmet need for family planning if she: 1. is married or in consensual union and in reproductive age (15-49 years) 2. is fertile (infecund women are identified based on their ability of childbearing and contraceptive history) 3. wants to have no more children or to postpone child bearing by at least two years 4. do not know when or if they want another child 5. is using neither a traditional nor a modern method of contraception 6. is pregnant or in the post partum period and her latest pregnancy is mistimed or unwanted and has not used any contraceptive method before the conception 16 . Unmet need for spacing is applied to non pregnant and non post partum women who are not using a FP method, who want more children but not for at least two or more years or are not certain whether they want to have another child or are not certain when they want to have another child or in case of pregnant females whose pregnancies were mistimed and had not used any form of contraception before the conception or in post partum women whose last births were mistimed and not used any form of contraception before the conception.
Unmet need for limiting is applied to women who do not want children at all but who are not using any form of contraception or pregnant females whose pregnancies were unwanted and who had not used any form of contraception before the conception or post partum women whose last births were unwanted and who had not used any form of contraception before the conception 16 ( Figure 1). The level of unmet need in a country is always changing, depending on the interplay of two factors, fertility desires and contraceptive use. Westoff and Bankole have observed it as a "moving target". It rises as more women want to control their fertility without contraceptive use, and it falls as more use contraception or change their preferences to have more children. Moreover, even where the proportion of women with unmet need is declining, the absolute number with unmet need may be growing because the population in the child bearing age is growing 18 .

Worldwide estimations of unmet need
Unmet need was first assessed using the World Fertility Survey, followed by Contraceptive Prevalence Surveys (CPS) conducted from 1978 to 1984 including only non pregnant and non postpartum women. The third was DHS using the standard definition including pregnant and postpartum women 16 . Globally, unmet need has been estimated on four occasions using DHS data. The prevalence for unmet need in the developing world varied from 11% to 24% (average 17%). It was around 24% in Sub -Sahara Africa, 16% in North Africa, Middle East and Asia, 14% in Latin America and 11% in Central Asian Republics while in West Africa, having a range from 16 to 34%. Overall, 80% of estimated global unmet need came from countries being surveyed 19 .
Prevalence and proportion for limiting and spacing were similar across the Asian region except in Pakistan where the majority was for limiting. However, in Sub Saharan Africa, 65% was for spacing, where as in Latin America it was only 42%. In spite of extensive family planning programmes, unmet need in Nepal remains high at 25% with 9.5% for spacing and 15.5% for limiting 16  Another example is Moldova where withdrawal is common; when confined to modern methods, unmet need increases from 7 to 31% 2 . In order to assess the unmet need for FP in Europe, data was analyzed from Fertility and Family Surveys (FFS) conducted in recent years in selected ten states. It was found to be 3% in two European countries (Belgium and Spain) and below 10% in most. Unlike in developing countries, the contribution for the unmet need by pregnant individuals is relatively small probably due to lesser number of unwanted pregnancies continued in developed countries where abortions are legalized and rates are relatively high 17 . In USA, analysis of data in the National Survey of Family Growth revealed that unmet need was 11% while 49% of pregnancies were unintended and 54% of these ended up with induced abortions 20

Trends of unmet need in Sri Lanka
In Sri Lanka, World Fertility Surveys ( In the study conducted in Gampaha MOH area, reasons for non use of modern contraceptives were fear of side effects (45.8%), infrequent intercourse (31.9%) and perceived low risk of pregnancy (23.6%) where multiple responses have been allowed 22 .
In the study conducted in District 1 Colombo Municipal Council, 71% of non users of modern methods gave community factors including lack of awareness, fear of side effects and husband's disapproval. Twenty nine percent were service factors including low postpartum coverage, side effects due to depo provera and intrauterine devise (IUD) and fear of IUD insertion procedure 23 . In Kalutara district, reasons identified for unmet need for FP were low perceived risk of pregnancy (36.2%), fear of side effects (30.5%) and less frequent sexual intercourse (19%) 24 . Globally, identified contributing factors for unmet need for FP are low mean age at marriage, low female education and gender discrimination 18 . In Sri Lanka, there had been increased association between unmet need and low levels of education until 1993, which has disappeared thereafter in DHS 2000 and 2006/7. There was no statistical relationship with sector of residence or age of the participants in any of the DHSS. Although rural areas had the lowest unmet need (6.8%) in comparison to urban (9.5%) and estate (11.1%) sectors in DHS 20066/7, this difference was not statistically significant 21 . The study conducted in Gampaha district revealed statistically significant increased risk of unmet need for FP in relation to educational status of below primary education, reduced level of sexual contact, intention to attempt for an induced abortion if conceived, unawareness of the existence of a law on induced abortion and unawareness of the risks of induced abortions 22 . In the Kalutara district study, a significantly increased risk of unmet need was found to be associated with being older than 35 years, having an education below primary level and being unemployed, having sex less frequently than once a week, desire of not having any more children, not expecting to use a modern FP method in future and not having counseling in FP 24 .

Consequences of unmet need for FP
The only sequela of unmet need is unintended and thus unwanted pregnancy, with its disastrous consequences leading to induced abortions. Induced abortions are mostly unsafe in developing countries, subjecting women to unsafe procedures with high risk of mortality and morbidity like chronic pelvic inflammatory disease, infertility and associated ectopic pregnancies, premature deliveries with added weight of psychological distress. Continuation of such pregnancies bears the risks of adverse pregnancy outcomes (low birth weight, small for gestational age and preterm birth) resulting postnatal morbidity and infant deaths 25 . In 1987, an estimated 26-31 million legal and 10-22 million clandestine abortions were performed worldwide, with the rate of illegal abortions being 35 per 1000 women in the age group of 15-44 years. The same rate continued until 1995 and decreased to 29 by 2008. But the rate of unsafe abortions increased from 44% in 1995 to 49% in 2008 because the contribution towards global abortions by developing countries increased from 78% in 1995 to 86% in 2008 27 . In those countries, safe abortion practices are not available although abortion is legalized on broad grounds.

Impact of Meeting Unmet Need
Starting a modern family planning method by each woman in the developing world with unmet need will prevent 52 million unintended pregnancies annually; thus preventing 22 million abortions; of which 60% occur now in the developing world. Providing these services and supplies would cost an additional $3.9 billion per year, but the savings would ultimately dwarf that figure. As seen in a typical low-fertility Latin American country, every dollar spent on family planning saves $12 in health and education costs from averted pregnancies, abortions, births and complications 28 . Reducing unmet need by accepting FP would eventually increase the birth intervals of siblings. It has been revealed that children born having spacing more than two years were 1.5 times more likely to survive the first week of life, 2.2 times more likely to survive the first 30 days of life, 2.3 times more likely to survive the first year of life and 2.4 times more likely to survive up to age five. Further, compared to women who give birth after a 9-11 months interval, women who have their babies after a 27-32 months interval are 1.3 times more likely to avoid anemia, 1.7 times more likely to avoid third trimester bleeding and 2.5 times more likely to survive child birth 11 . Thus, it is evident that having strict abortion law is not supportive of reducing unsafe abortions and related consequences, but the only way is to reduce unmet need for FP and the incidence of unplanned pregnancies is by using effective FP methods.