Targeting Access to Reproductive Health: Giving Contraception More Prominence and Using Indicators to Monitor Progress

Abstract

Unmet need for contraception represents a major failure in the provision of reproductive health services and reflects the extent of access to services for spacing and limiting births, which are also affected by personal, partner, community and health system factors. In the context of the Millennium Development Goals, family planning has been given insufficient attention compared to maternal health and the control of sexually transmitted infections. As this omission is being redressed, efforts should be directed towards ensuring that an indicator of unmet need is used as a measure of access to services. The availability of data on unmet need must also be increased to enable national comparisons and facilitate resource mobilisation. Unmet need is a vital component in monitoring the proportion of women able to space and limit births. Unmet need for contraception is a measure conditioned by people's preferences and choices and therefore firmly introduces a rights perspective into development discourse and serves as an important instrument to improve the sensitivity of policy dialogue. The new reproductive health target and the opportunity it offers to give appropriate attention to unmet need for contraception will allow the entry of other considerations vital to ensuring universal access to reproductive health.

Résumé

Le besoin insatisfait de contraception représente un échec majeur dans la prestation de soins de santé génésique et mesure l'accès aux services d'espacement et de limitation des naissances, qui est aussi influencé par des facteurs personnels, des partenaires, communautaires et du système de santé. Dans le contexte des objectifs du Millénaire pour le développement, la planification familiale a reçu moins d'attention que la santé maternelle et la lutte contre les infections sexuellement transmissibles. Les activités entreprises pour corriger cette omission doivent garantir l'utilisation d'un indicateur du besoin insatisfait comme mesure de l'accès aux services. Il faut aussi accroître la disponibilité de données sur le besoin insatisfait pour permettre les comparaisons nationales et faciliter la mobilisation de ressources. Le besoin insatisfait est un élément essentiel pour évaluer la proportion de femmes capables d'espacer et de limiter les naissances. Le besoin insatisfait de contraception est une mesure conditionnée par les préférences et les choix personnels et il introduit donc fermement une perspective des droits dans le discours sur le développement. C'est par conséquent un instrument précieux pour sensibiliser le dialogue politique. La nouvelle cible en matière de santé génésique et l'occasion qu'elle offre d'accorder suffisamment d'attention au besoin insatisfait de contraception permettront l'entrée d'autres considérations capitales pour assurer un accès universel à la santé génésique.

Resumen

La necesidad insatisfecha de recibir anticonceptivos constituye un fracaso en la prestación de servicios de salud reproductiva y refleja la importancia de tener acceso a los servicios para espaciar y limitar partos, que también son afectados por factores personales, así como de la pareja, comunidad y sistema de salud. En el contexto de los Objetivos de Desarrollo del Milenio, se le ha dado muy poca atención a la planificación familiar en comparación con la salud materna y el control de las infecciones de transmisión sexual. A medida que se revalúa esta omisión, se deben dirigir esfuerzos hacia garantizar que un indicador de la necesidad insatisfecha sea utilizado como una medida del acceso a los servicios. La disponibilidad de datos sobre dicha necesidad también debe ampliarse para permitir comparaciones nacionales y facilitar la movilización de recursos. La necesidad insatisfecha es un elemento vital en el monitoreo de la proporción de mujeres con posibilidad de espaciar y limitar partos. La necesidad insatisfecha de anticoncepción es una medida condicionada por las preferencias y decisiones de las personas; por tanto, introduce firmemente una perspectiva de derechos en el debate del desarrollo y sirve como un instrumento importante para mejorar la sensibilidad del diálogo en políticas. La nueva meta de salud reproductiva y la oportunidad que ésta ofrece para prestar la atención adecuada a dicha necesidad permitirá que se tomen en cuenta otros factores vitales para garantizar acceso universal a la salud reproductiva.

Key Words:

• family planning
• Millennium Development Goals
• reproductive health services
• unmet need
• indicators

Traditionally, outcome measures such as contraceptive prevalence rate and total fertility rate have been used to monitor the outcome of family planning programmes. In addition, the concept of unmet need, that is, the proportion of women at risk of pregnancy who do not want to conceive or give birth within the next two years or at all, and who are not using a method of contraception, has long been used to inform policy and programmes and has been refined progressively over the last three decades.^1–5

Defining unmet need

A series of questions in population-based surveys is used to identify the population at risk of pregnancy and assess when or whether they want a(nother) birth. Women who want to delay or avoid a(nother) birth who are not using family planning are considered to have unmet need, as are women who report non-use of contraception prior to their latest unintended or ill-timed pregnancy. Women who are currently pregnant or still amenorrhoeic post-partum are assessed as having unmet need if that pregnancy was not desired at that time or at all.

This measure supplements the outcome measures used by focusing on those who are not achieving their preferences to delay or space births and by expanding consideration to the multiple determinants of fertility outcomes.⁶

International policies on reproductive health and family planning

In the Programme of Action adopted in 1994 in Cairo at the International Conference on Population and Development (ICPD), the perspective of the individual is crucial: programmes should enable individuals to decide on the number and spacing of their children.⁷ Accordingly, personal perspectives are central to decisions regarding the utilisation of services. The assessment of progress therefore cannot rely on contraceptive prevalence rate or total fertility rate alone; instead, it will be necessary to measure the extent to which services are responsive to stated preferences. Thus, in setting national targets, there is no optimal level of contraceptive prevalence independent of the informed, voluntary choices and exercise of rights of individuals and couples.

The ICPD Programme of Action stated that: “All countries should strive to make accessible through the primary-care system, reproductive health to all individuals of appropriate ages as soon as possible and no later than the year 2015”.⁷ This goal of universal access was subsequently re-affirmed by world leaders at the World Summit in 2005, whose outcome document stated that: “We commit ourselves to … achieve universal access to reproductive health by 2015, as set out at the International Conference on Population and Development, integrating this goal in strategies to attain the internationally agreed development goals, including those contained in the Millennium Declaration aimed at reducing maternal mortality, improving maternal health, reducing child mortality, promoting gender equality, combating HIV/AIDS and eradicating poverty”.⁸

This declaration initiated an extended discussion, fraught with political pressures, on how to translate the World Summit recommendations into the already established international framework for the monitoring of the Millennium Development Goals (MDGs). After many interventions by member states, the Secretary-General recommended in August 2006 that new targets, including one for reproductive health, be added⁹ and when the General Assembly took note of the report of the Secretary-General in October 2006, the recommendation became actionable.

Whereas much has been done to improve access to services in the areas of maternal health and HIV control, there is general agreement that family planning services have not been given due prominence.¹⁰ In 1999, at the five-year review of the implementation of the ICPD Programme of Action,¹¹ it was explicitly stated that the gap between contraceptive use and the desire of individuals to space or limit the size of their families should be addressed by eliminating unmet need by 2015. Such gains are expected to be achieved through strictly voluntary programmes. Though benchmarks were proposed, monitoring efforts and programmatic action have not been sufficiently intensified though recent political commitments might build further momentum.

Monitoring of access

The contraceptive prevalence rate is well entrenched in numerous initiatives for the monitoring and evaluation of reproductive health services, e.g. the joint WHO/UNFPA technical consultation for the measurement of access to reproductive health services. Besides the contraceptive prevalence rate, three other indicators were selected: skilled attendance at birth, knowledge of HIV prevention and treatment for urethral symptoms.¹² More recently, a World Health Organization technical consultation on reproductive health indicators¹³ recommended the incorporation of contraceptive prevalence rate, unmet need for contraception and the age-specific fertility rate of 15–19 year olds into monitoring systems for assessing progress towards the Maternal Health Goal (Goal 4) of the MDGs. Furthermore, there was a call for national level work to accelerate the development of measures of the coverage of emergency obstetric care.

As a supplementary aid to interpretation, it was further recommended that contraceptive prevalence and unmet need be used to calculate the proportion of demand for family planning being satisfied.¹³ This measure, calculated as the ratio of prevalence to the sum of prevalence and unmet need, is included in Demographic and Health Survey reports and available on the ORC/MACRO website's StatCompiler.¹⁴ Unmet need should ideally move towards zero, an impractical albeit aspirational target that respects the desire to space or limit births.

The measure of the proportion of demand for family planning that is satisfied is particularly sensitive to regional, educational and wealth disparities. Neither contraceptive prevalence rate alone nor unmet need alone would capture the extent of progress towards equity in the attainment of fertility preferences but taken together,^5,15 they can be used to monitor progress towards more equitable reproductive health services.

Clarity about the definition and use of both the concept of “need” and the related extension to “unmet need” is required. A definition of need that does not incorporate the perspective of the user would be inappropriate from the vantage point of reproductive rights, as emphasised in the Programme of Action of the ICPD. However, the preferences of individuals are affected by perceived social support and the quality and availability of services. The barriers to translating expressed preferences, such as for longer birth intervals, into actual uptake of service are multiple. Intention to use a contraceptive method has been suggested as a more appropriate criterion for assessing the level of unmet need but the relation between intention to use and desire to prevent or delay births is itself imperfect and complex.¹⁶

Reasons for unmet need

Research identifies several barriers to use of family planning in health systems, communities and families: non-communication or disagreement about fertility preferences (with the former being more important); lack of information about method options and availability; health concerns and fear of side effects, some based on information failures; family or community disapproval; women's low decision-making power in relation to their partner or his family; cost of services; opportunity or social costs of acquisition; and perceptions of limited availability, access and quality of services.¹⁷ In particular settings, misinformation, mistrust and mistreatment also play a role.¹⁸ The ability of a national or district health administration to remove these barriers is closely related to several key development issues, including the commitment to good health care, to providing services equitably, to empowering women and their partners to make effective choices and to addressing the impact of demographic dynamics.

The way forward: the new target on reproductive health

The new target on reproductive health will need to be agreed upon, but whatever the outcome of the technical review to do so and the impact of the political context, countries are the final arbiters of their priorities and the means for monitoring them.

Family planning is a crucial component of sexual and reproductive health.^7,15,19 Major discussions are currently ongoing for the selection of indicators which will be used in national, regional and international efforts to monitor universal access to reproductive health. An international consultation in December 2003 had recommended the monitoring of access through the following four indicators: births attended by skilled health personnel, contraceptive prevalence and knowledge of HIV-related prevention practices, which are three indicators that were already in the MDG set, and additionally, men reporting treatment for urethritis.¹² Awareness of the major limitations of these indicators led to a re-opening of the entire issue. Current concern consists among the other aspects raised here of redressing the insufficient global priority being accorded to family planning and adolescent fertility. It is anticipated that the new global target on reproductive health will intensify attention at the national level; high-level policy commitments have already been adopted for such monitoring at the international level¹⁹ and in the African region.²⁰ Despite some variation in the approaches, national development strategies are being oriented towards the achievement of the MDGs. Incorporation of reproductive health concerns in national plans and monitoring frameworks will be critical to future progress.

There is a serious effort underway on the part of the UN to ensure that development investments are oriented towards attainment of the MDGs.^8,21 Progress in this regard will require a coordinated international effort to make sure that key indicators are regularly monitored. To some extent, the costs of large-scale surveys have represented a barrier to wider measurement of indicators such as unmet need. Other MDG indicators have also had far from satisfactory coverage.²²

Improved coverage of family planning and other MDG-relevant indicators could also emerge from a strong consensus for UN system support for a series of short modules that could be uniformly and consistently applied, with technical back-up for comparative analyses, to advance policy dialogue on programme priorities. The current international measurement of unmet need in DHS-type surveys should serve as a starting point for intensified national monitoring. Ideally, countries should consistently monitor the coverage of and access to reproductive health services every three years.

Several other issues need to be addressed for the full implementation of monitoring at national level of family planning indicators, which can inform expansion of monitoring of other gaps in reproductive health. First, at national level, a more detailed and analytic approach to the presentation of reports of unmet need would advance its use in programming. Particular attention is needed to give adequate weight to programme efforts to address unmet need and to ensure correct and consistent use of an appropriate method, as well as attention to contraceptive preferences of current contraceptive users in relation to timing of births.²³ In national monitoring, more detailed analyses of how the components of unmet need vary in different sub-populations can inform programme priorities and identify needed interventions, such as post-partum counselling.

Second, exploration of the possibility of simplifying the current approach to measurement should be undertaken to reduce the burden on survey respondents. Unmet need continues to serve well as an omnibus measure of success in realising fertility preferences.

Third, the current measurement of unmet need for family planning covers only contraception but does not include recourse to abortion, which constitutes a significant indicator of contraceptive method failure and incorrect, inconsistent or non-use of contraception. Further research and data analysis should seek to monitor this dimension of reproductive health. The Programme of Action of the International Conference on Population and Development recommended the strengthening of efforts to address the major public health impact of unsafe abortion.⁷ Its five-year review in 1999 prioritised the importance of access to services for the reduction of mortality and morbidity from abortion.¹¹ Monitoring of abortion, and in particular unsafe abortion, levels will improve our understanding of women's reproductive health needs, a good example being the recent estimate, based on national data available in only 13 countries, that some five million women per year globally are hospitalised for complications of unsafe abortion.²⁴

Additional qualitative analyses could examine restricted choices among contraceptive methods, quality of service delivery and the lack of an infertility component in programmes. Improved measurement of unintended pregnancies in general could incorporate both conventional unmet need and the extent of recourse to abortion in order to provide further evidence of the need for effective contraceptive services and also, as appropriate, safe abortion services. Other unmet needs, such as those for improved access to a broad range of reproductive, maternal and newborn health interventions could be assessed to better monitor service improvements.²⁵

Fourth, the actual levels of unmet need among 15–19 year olds most often exceed those observed in the overall reproductive age group. As has been urged in the past, population surveys must systematically include all sexually active women, including young and unmarried women, in both numerators and denominators, to avoid underestimation of the extent of need for services.¹⁵

Finally, examination of observed fertility rates and their relation to reported contraceptive use is required. In settings where the utilisation of family planning meets with community and spousal disapproval, e.g. high fertility settings with low empowerment of women, attention should be given to possible under-reporting of contraceptive use. Geographical areas where fertility is lower than prevalence reports would suggest, and where other proximate determinants such as abortion, breastfeeding and spousal separation cannot account for the discrepancy, need particular attention. This approach would avoid over-estimation of unmet need.

Detailed studies such as this could be done in the context of a set of modules that can be widely incorporated in surveys to monitor multiple dimensions of progress towards universal access to reproductive health. Programmatic progress also needs monitoring.^4,26 A set of programme monitoring measures, beyond those used to monitor the MDGs, needs to be finalised and implemented. The heightened priority to family planning that measurement of unmet need, contraceptive prevalence and satisfaction of total spacing and limiting desires is intended to catalyse must be supported by resources for regular measurement and improvement of access.

Some dimensions of universal access to reproductive health are currently included under existing MDG goals and targets, i.e. reducing maternal mortality and HIV/AIDS prevention. Family planning needs to be monitored under the new target. Other gaps in reproductive health services, such as lack of access to skilled birth attendants, emergency obstetric care, information and the means to prevent and treat sexually transmitted infections, including HIV, infertility treatment and other interventions, also need urgent action. But unmet need for contraception is a measure conditioned on people's preferences and choices and firmly introduces a rights perspective into development discourse. It therefore serves, if used well, as an important instrument to improve the sensitivity of policy dialogue and allow the entry of other considerations vital to ensuring universal access to reproductive health.

Acknowledgements

The views expressed in this paper should not be construed as necessarily reflecting those of the institution.