A scoping review on determinants of unmet need for family planning among women of reproductive age in low and middle income countries

Background Poor access and low contraceptive prevalence are common to many Low- and Middle-Income Countries (LMICs). Unmet need for family planning (FP), defined as the proportion of women wishing to limit or postpone child birth, but not using contraception, has been central to reproductive health efforts for decades and still remains relevant for most policy makers and FP programs in LMICs. There is still a lag in contraceptive uptake across regions resulting in high unmet need due to various socioeconomic and cultural factors. In this mixed method scoping review we analyzed quantitative, qualitative and mixed method studies to summarize those factors influencing unmet need among women in LMICs. Methods We conducted our scoping review by employing mixed method approach. We included studies applying quantitative and qualitative methods retrieved from online data bases (PubMed, JSTOR, and Google Scholar). We also reviewed the indexes of journals specific to the field of reproductive health by using a set of keywords related to unmet contraception need, and non-contraception use in LMICs. Results We retrieved 283 articles and retained 34 articles meeting our inclusion criteria. Of these, 26 were quantitative studies and 8 qualitative studies. We found unmet need for FP to range between 20 % and 58 % in most studies. Woman’s age was negatively associated with total unmet need for FP, meaning as women get older the unmet need for FP decreases. The number of children was found to be a positively associated determinant for a woman’s total unmet need. Also, woman’s level of education was negatively associated – as a woman’s education improves, her total unmet need decreases. Frequently reported reasons for non-contraception use were opposition from husband or husbands fear of infidelity, as well as woman’s fear of side effects or other health concerns related to contraceptive methods. Conclusion Factors associated with unmet need for FP and non-contraception use were common across different LMIC settings. This suggests that women in LMICs face similar barriers to FP and that it is still necessary for reproductive health programs to identify FP interventions that more specifically tackle unmet need. Electronic supplementary material The online version of this article (doi:10.1186/s12905-015-0281-3) contains supplementary material, which is available to authorized users.

Prevalence of unmet need among women during the postpartum period.
Cross-sectional facility-based survey of 256 postpartum women between ages 17-40 having attended ANC services at Ife-Ife teaching hospital (data: 2003-04

Other:
-Association between women's educational level and demand for FP appears to be rather Ushaped. -Association between women's educational level and unmet need for limiting appears to be rather linear.

Mixed methods review
Unmet need as a concept: -Unmet need often not directly based on respondents' reported information, but rather on inferences made by researcher: 1) those women stating desire to space/limit childbearing; 2) those in 1) who would like to take actions to avoid births in form of FP rather than induced abortion or any other actions. -Unmet need likely underreported as current empirical practice excludes (temporarily) infecund women from being included into analysis. -Direct evidence for existing unmet need as concept provided by high incidence of reported unintended pregnancies (20-25% of births estimated in developing world to be unwanted). -Many women and men feel frustrated by their inability to adopt behaviors effectively preventing unintended pregnancies. -As with unmarried women, there has been limited empirical research on men's unmet need for FP.

Relationship between unmet need and met need for FP:
-Reduction in fertility (i.e. increase in FP use) among those women at risk for unwanted births represents a disproportionate contribution to overall reported fertility decline. -Substantial increases in prevalence of FP use (i.e. substantial decline in fertility) can be achieved in absence of changes in demand for children through meeting the need for FP.

Relationship between unmet need and demand for FP:
-Category "unmet need" often composed of women who vary considerably in their demand for FP.
-Many women with unmet need remain unlikely to adopt FP use any time soonnot primarily due to lack of access, but because of extreme reluctance to FP use due to negative perception of not conceiving (i.e. social, cultural, and health concerns). -Only fraction of unmet need represents with a latent demand for FP susceptible to conversion into use. -Only once FP practice is cost-free (including cultural, social, health, financial, and time costs) all women and men with unmet need could be regarded as having a latent demand for FP. -Stronger correspondence between "intention to use" (not "unmet need for FP") and subsequent FP use.

Redefining "unmet need":
-Unmet need should include qualitative as well as quantitative dimensions.
-FP users may still have FP needs; high FP prevalence can coexist with significant unmet need for FP.

Scoping Review
Reasons for non FP use: -User Level: social relations (e.g. partner's opposition, desire for more children), low female literacy, method-related misconception or fear of FP); lack of culturally-sensitive IEC/behavior change programs -Family Level: opposition from family members, lack of support from mother-in-law, dependency on family norms, lack of decision-making autonomy of women (including health and emergency situations); lack of engagement of FP programs with older women at community level. -Community Level: persistent myths about modern FP, religious opposition/misinterpretation; lack of adequate social marketing, lack of appropriate health-seeking behavior communication, lack of grassroots program making FP acceptable as a social norm -Health Service Level: limited access, poor service quality, ineffective promotion of modern FP, weak public sector outlets (especially in rural/peri-urban areas) -Other Levels: social marketing through radio/TV often not sufficiently open and direct, outreach hampered by poor traffic infrastructure, little alignment between youth/women development programs and health/population strategies; lack of use of electronic media for social marketing -State Level: poor integration of FP services in primary health care, little cross-sectional strategies (e.g. promotion of girls' education), poor investment and evaluation of social marketing campaigns/FP programs, donor funding oriented toward vertical programs, hampering government policies   persisting traditional beliefs among women that ancestors are against FP practices, which leads to ancestral disapproval with withdrawal of spiritual blessings or even a woman's death when practicing FP.

WOMEN'S COPING STRATEGIES USING FP:
-Autonomy and social respect: women adopt complicated/subtle reproductive/sexual strategies to achieve some degree of sexual autonomy while still maintaining their social position in family and community. -Examples for coping strategies: to give husband impression FP practice is his own decision; to create additional sources of income in order to purchase FP independently of husband's approval; to resist unwanted sexual advances by discrediting husband within community; to secretly use of FP.

MEN'S FEAR USING FP:
-Social norms of marriage: wives are acquired through bride-wealth payments (sheep, cattle); women are therefore considered husbands'/husband's family's property; married women obligated to bear children in return; women taking control of reproduction suggests their wish to not meet marriage obligations, posing threat to strong patriarchal traditions. -Male perception of FP: FP programs disturb existing social order by providing women living in traditional and gender-stratified societies with technology facilitating control of reproduction,. -Reproductive obligations: steady supply of children considered essential by society that depends on strong male lineages; while women's reproductive focus is primarily on assuring health of their offspring (e.g. through spacing), men's reproductive focus emphasizes the security of having many children (to overcome threats posed by child mortality/infertility). -Fear of infidelity/promiscuity: women practicing FP are perceived as unfaithful to their husbands or inclined to abandon their families; from male perspective potential loss of spouse creates ridicule of man's status/honor/pride and represents major economic threat given initial bride-wealth investment. -Fear of losing control: men are sole decision-makers; FP decisions require therefore husband's consent; women do agree that husband's authority is critical; women who act independently on FP decisions and encounter problems due to FP use are thus to be blamed for damaging themselves and the family.

CONSIDERATIONS FOR FP PROGRAMMING:
-Active involvement of local leaders (chiefs, village committees, community assembly members) and women groups in community health and FP themes. -Outreach to men by field workers using village-level male associations (farming, drumming), home visits. -Support for women by protecting women's interests and safety; this requires sustained attention, worker training, and frequent meetings with service-delivery staff. FGD = focus group discussion; FP = family planning Community-based cross-sectional study including a total of 6 FGD with each 8-14 evermarried women between the ages of 19-50 and 15 semistructured in-depth interviews with currently married women between the ages of 25-53.

Content analysis of transcripts after translation into
English.

FP USE:
-FP methods used: a) FGD: periodic abstinence and female sterilization most commonly practiced methods; b) Interviews: attitudes towards modern FP methods differ depending on educational/ socioeconomic backgrounds; copper IUD is most commonly used reversible FP method; abortion considered back-up when a woman conceived shortly after giving birth or abstinence method failed. -Reasons for FP use: a) Spacing: allows physical recovery from labour before next pregnancy; prevents challenges of household duties due to multiple infants; allows offering full course of breastfeeding to each infant; b) Limiting: allows smaller family size; allows adequate education for each child, allows improving social family's status. -FP and social norms: concept of 'self control' (i.e. abstinence and/or withdrawal) most frequently practiced and considered an admirable personal virtue; having three or more children considered irresponsible, however, preference for male offspring makes women with female offspring to bear additional children; women reluctant to adopt long-term FP methods as they cannot reversed easily when husbands is away, which implies female infidelity; abortion considered dangerous, shameful (result of sexual immoderation), and needs to be concealed. SOCIAL RISKS: -Family pressure: large family size considered an ideal by extended family; older relatives pressure couples to continue bearing children and forbid use of FP; Hindu culture includes a number of menstrual taboosclose proximity of extended family members makes secret FP use difficult as menstruation cycles of a women is indirectly observed by household members. ECONOMIC RISKS: -Vasectomy vs. tubal ligation: female sterilization more prevalent than male sterilization despite easy availability, no cost, and much higher incentive payment for vasectomy; general believe vasectomy to permanently disable men from doing hard labour, thus removing primary source of household income. SIDE EFFECTS: -IUD: believed to damage uterus and health, as IUD causes heavier, longer, more frequent menses; IUD users face exclusion from domestic/religious activities due to change in menses (menstrual taboo). -Oral contraception: hardly used for FP, instead frequently used to circumvent menstrual taboo by taking OCP over only few days to delay menstruation; OCP abuse and overdose without physician guidance, leading to excess side-effects (abdominal pain, nausea, vomiting, vertigo, vaginal infections).
-Vasectomy: potential vasectomy failure as strong disincentive for women as this casts doubt on fidelity of wife; most women consider female sterilization better option regardless of more invasive nature.

INFORMATION AND KNOWLEDGE ON FP:
-Source of information: primarily through female relatives and friends; educated women through school; FP officials never visited or treat women rudely.

Content analysis of transcripts after translation into
English.

DISSATISFACTION WITH FEMALE FP METHODS:
-Male perception of female FP: women are perceived to carry the physical burden of FP side effects, men however consider themselves indirectly affected by FP side effects (women's reduced sexual pleasure, increased risk of female infertility/illness, irregular/prolonged bleeding, vaginal dryness, decreased libido); concerns of FP induced delayed return to fertility, permanent loss of fertility, congenital abnormalities; FP side effects cause adverse economic effects on household as result of women's reduced ability to endure physical demands of agricultural labor; additional medical care costs to treat women's discomfort due to FP use. -Male coping strategies: especially increased bleeding is considered as limiting the opportunities for men to have sex with their partner, and serves as motivation for men to develop extramarital sexual relations; requests by men for spouses to discontinue FP use altogether.

DISSATISFACTION WITH MALE FP METHODS:
-Unmet need for male FP: main incentive for FP is economic burden of raising large families; only limited access to male-led method (except for condom, vasectomy) which results in additional disapproval of FP by men; vasectomy perceived as losing one's masculinity, thus inacceptable FP option for men; relative strong male interest and preferences for male version of birth control pills. -Female perception of male FP: older men consider condoms designed for unmarried/younger men, not tailored to older sexually active men; use of condoms associated with distrust among couples.

FP AS WOMAN'S DOMAIN:
-Gender roles: role of childbearing, child-rearing, fertility and FP assigned to women; generating family income assigned to men; use of men's limited time and mental preoccupation to discuss FP considered burdensome and distractive.

Content analysis of transcripts after translation into
English.

LACK OF INFORMATION/MISCONCEPTIONS:
-Knowledge of FP: lower among men compared to women; most men could name at least one FP method, only few understood how this particular method actually worked -Source of FP knowledge: men receive FP information mainly from the radio.
-Fear of FP use: rumors about oral contraceptives to be inefficient in preventing pregnancies, to create permanent infertility or cause congenital malformations; rumors about condoms to spread HIV. FP SIDE-EFFECTS: -Male concerns regarding FP side-effects: general sickness, menstrual disturbance, weight gain/loss, nausea, weakness, infertility, malformation of newborns; concerns about side-effects more pronounced among men with limited access to health care facilities/FP information. FP SERVICES/SUPPLIES: -FP availability: unavailability of FP important barrier for men using FP; supply of FP devices generally unreliable; only very limited range of FP methods available due to national shortages.
-FP access: long distance to nearest FP outlet as barrier receiving FP services; relatively high cost/low availability of transportation/time to visit clinic; men perceive their accessibility to FP service generally lower as women. FP PERSONNEL: -Skepticism/distrust: intentions and motivation of FP personnel/programs encouraging individuals to use FP unclear to users and non-users; providers seem more concerned with own financial/personal gains than needs of community; concerns that FP providers withhold important information about FP associated health risks; -Perceived quality of FP services: providers sometimes rude, dismiss/disregard clients' fears about side-effects; although local language is used to communicate with clients, most FP supplies are from abroad with instructions for use not translated into local languages. -Male perception of FP services: men do not feel welcome at FP centers; fear discussing sensitive and private issues with female provider. -Couple counselling: counselling of couples by FP providers is rare; providers prefer to counsel men and women separately; female FP providers more comfortable counselling women than men; different information about FP given to men and women contributes to more mistrust between couples. COUPLE COMMUNICATION/TRUST: -Lack of communication between couples: attributed to perception that FP use is associated with promiscuity/infidelity; men report to be suspicious if wives make decision to use FP on their own. -Secret use of FP: high demand of injectable FP due to secret use of FP by women without husband's knowledge/approval. CULTURAL AND RELIGIOUS FACTORS: -Number of children/family size: men express desire for many children, which enhances prestige in community, ensures labour and social security; counteracts high rate of child mortality. -Patriarchal/patrilineal/polygamist society: preference for sons, as boys inherit father's clan and thus increase clan's power, status, longevity; competition between wives for husband's love often played out with number of children/sons borne by each woman. -Religion widely considered as barrier to contraceptive use, Anglican Church more accepting of modern methods compared to Catholic and Muslim denominations. preference of many children as they serve as labour force in farming activities; having as many children as possible facilitated by extended family support system; relatives influence number of children a couple might have; especially mother-in-laws put pressure on sons/daughter-in-laws to have more children than initially planned. -Urban norms: value of children in terms of costs involved in raising children (school, medical services, social amenities); having more children would mean incurring more costs. FGD = focus group discussion; FP = family planning

CONDOM KNOWLEDGE/BELIEVES:
-Source of knowledge: radio, public meetings/outreach, school, gossip; no clear understanding/ experience with condom use (access to knowledge higher in intervention communities). -Perception/misconception: belief that condoms are neither effective nor safe; condoms might be infected with HIV; condoms are white people strategy to harm Africans through promotion and distribution of old/inferior or HIV infected products. ATTITUDES TOWARDS CONDOM USE: -Positive attitudes: only few girls/women, mostly pupils, valued condoms as FP method.
-Negative attitudes: condoms reduce sexual pleasure (particularly men); no decision-making power regarding condom use (particularly women, commercial sex); no need if not interested in FP; leaving exposure risk to chance/God's will; perceived low personal risk of acquiring STI/AIDS; trust in partner; fear of stigma/rejection/punishment (infidelity, promiscuity); general suspicion of condoms. CONDOM USE: -Consistency/frequency: majority of respondents have never used condoms; consistent use rare.
-Condom use men: only if they suspect to be at high risk of acquiring a disease.
-Condom use women: many women use only at partner's initiative; few insist on use during intercourse. CONDOM AVAILABILITY/ACCESS: -Condom outlets: shops, health facilities, local promoter-distributors (intervention communities).
-Stigma condom purchase: belief health workers, salespeople, and distributors would not keep requests for condoms confidential (especially young people); customers embarrassed to request condoms. -Access: general lack of demand; costs appear not to be a barrier; supplying rural areas and monitoring condom sales requires disproportionate amount of time and is not cost-effective. lack of supplies/poor distribution of commodities. -Human resource: Need for health worker training; lack of skilled providers; inability to access skilled providers due to home deliveries; health extension workers to provide outreach. -Financial resources: availability of sufficient funding for FP. FGD = focus group discussion; FP = family planning Community-based cross-sectional study including 9 FGD with each 8-12 participants (for women and men each 1 with singles between the ages of 15-20, each 1 with married individuals between the ages of 15-20, each 1 with married individuals between the ages of 25-30, each 1 with married individuals between the ages of 35-40, and 1 with male community leaders) and 25 indepth interviews with TBA of same communities.
Content analysis of transcripts after translation into Spanish.

COMMUNITY INFLUENCES:
-Approval of FP: disapproval of those openly practicing FP; especially women suspected of using FP are severely criticized; one would have to hide FP use from friends and family; community norms dictate unmarried women to not be knowledgeable in reproduction; community leaders resistant to accept FP. -Source of FP knowledge: Catholic Church offering premarital classes to encourage prospective couples to have all the children God sees fit; FP considered equivalent to abortion, which is murder or mortal sin. -Gender roles and FP: men and women felt both partners should be involved FP decisions, while other family members should not; traditionally, men are decision-makers (including FP); women face difficulties discussing FP without being accused of unfaithfulness/infidelity. FP PURPOSES: -Social norms on FP: having children considered purpose of human existence, principal reason for marriage; traditionally, large families considered favorable, as it provides economic support in old age and strength to Mayan identity; FP use associated with laziness in fulfilling God's plan. -Women's interest in FP: older women perceive many and closely spaced children bad for health, family finances, household workload, providing sufficient food for everyone (including breastfeeding); interest in birth spacing; -Men's interest in FP: large families reduce size of each son's share of land; interest in birth spacing.
-Knowledge of FP: mostly traditional methods (postpartum abstinence, long periods of breastfeeding); modern FP primarily associated with birth limiting/abortion, not associated with birth spacing.

MODERN FP METHODS:
-Knowledge of modern FP: men and older women most knowledgeable about modern methods (OCP, condom, IUD) -Perception of OCP: causes weight/loss, general debilitation, cancer, intrauterine child death, maternal death; too expensive to use. -Perception of condoms: only used by young unmarried men; for disease prevention, not pregnancy prevention; causes female genital cancers. -Perception of IUD: causes weight gain, maternal death. TRADITIONAL FP METHODS: -Knowledge of traditional FP: calendar rhythm method common, but incorrectly used; herbal, mineral, medical (intravaginal aspirin) considered as natural/traditional contraceptives/abortifacients (usually used by women who got pregnant prior to marriage); postpartum abstinence. FP SERVICE PROVISION: -Availability: government centers, health posts; FP information only available in Spanish; only directed to women, not to men; -Perception of community: distrust of motives of FP promoters, especially among men. -Perception of TBA: majority feels FP should be provided through TBA; concern that FP services are not wanted by communities. FGD = focus group discussion; FP = family planning; TBA = traditional birth attendant(s)