2
The Need and Demand for New Contraceptive Methods

Issues of Terminology

In the context of family planning and contraception, the terms "need" and "unmet need" are applied, qualitatively and quantitatively, in several overlapping and intersecting ways, depending on the purposes of their application. They may incorporate the notions of "demand,'' "unmet demand," or "potential demand" or even be used interchangeably with those terms; and all terms are almost inevitably entangled with various conceptualizations of "preferences" and "intentions." The definition and computation of who "needs," "demands," "prefers," and "intends" what, and under which circumstances, have been debated for well over a decade. The debate is, however, far from an arid academic exercise: Its results have always been significant for the design, implementation, and evaluation of family planning programs. Because the terminology debate is vitally connected to the commodities, that is, the fertility regulation technologies that are essential to family planning, it has large and necessary implications for the pace and direction of contraceptive research and development, as well as for the involvement of industry in R&D processes.

Accordingly, this chapter begins with issues of terminology and its quantitative implications, as a basis for thinking about the personal and public health components of current needs for contraceptive technologies in the United States and worldwide. Some of these needs are general , in the sense that they are needs for contraception; others, addressed more fully in Chapter 5, are specific needs for new contraceptive technologies which have, in the eyes of this committee, clear implications for the market. "General needs" include the consequences of



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--> 2 The Need and Demand for New Contraceptive Methods Issues of Terminology In the context of family planning and contraception, the terms "need" and "unmet need" are applied, qualitatively and quantitatively, in several overlapping and intersecting ways, depending on the purposes of their application. They may incorporate the notions of "demand,'' "unmet demand," or "potential demand" or even be used interchangeably with those terms; and all terms are almost inevitably entangled with various conceptualizations of "preferences" and "intentions." The definition and computation of who "needs," "demands," "prefers," and "intends" what, and under which circumstances, have been debated for well over a decade. The debate is, however, far from an arid academic exercise: Its results have always been significant for the design, implementation, and evaluation of family planning programs. Because the terminology debate is vitally connected to the commodities, that is, the fertility regulation technologies that are essential to family planning, it has large and necessary implications for the pace and direction of contraceptive research and development, as well as for the involvement of industry in R&D processes. Accordingly, this chapter begins with issues of terminology and its quantitative implications, as a basis for thinking about the personal and public health components of current needs for contraceptive technologies in the United States and worldwide. Some of these needs are general , in the sense that they are needs for contraception; others, addressed more fully in Chapter 5, are specific needs for new contraceptive technologies which have, in the eyes of this committee, clear implications for the market. "General needs" include the consequences of

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--> Figure 2-1 General needs for contraception, specific needs for new contraceptive methods, and the market created by these shared needs. unintended pregnancy, notably abortion and maternal mortality, and the changing requirements of the reproductive life span. "Specific needs" include sexually transmitted reproductive tract infections; lack of involvement of males in contraception; and contraceptive failure and side effects. Figure 2-1 presents this breakdown in graphic form. Market Demand In economics, "demand" has both volitional and authoritative dimensions, since it comprises the notions of desire to purchase and possess, as well as the power to do so. In classical microeconomic theory, demand has an iterative relationship with supply, a relationship that is mediated by the market, which transmits information about prices, quantities, and elasticities in each. However, application of traditional supply-and-demand concepts to understanding the role of demand in processes of technological innovation has not been very illuminating (Lotz 1993; Mowery and Rosenberg 1982). A more rewarding perspective is offered by marketing research, which distinguishes between "needs," "wants," and "demands'' in ways that are useful for thinking about development of new medical technologies in general and contraception in particular. In one analysis, a human need is defined as "a state of felt deprivation of

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--> some basic satisfaction," wants as "desires for specific satisfiers of these deeper needs," and demands as "wants for specific products that are backed up by an ability and willingness to buy them." The more explicitly needs are articulated as demands, the higher the likelihood that the "demander'' will be willing to pay for satisfaction of those needs (Kotler 1988). The concept of market demand introduces the important notion of "signals," or expressions that come from a potential user—or third-party population—with both the willingness and ability to pay for satisfying needs and wants that are assumed to be in some way "unmet" (Lotz 1993; Nelson and Winger 1977). These may be (a) very specific signals about product specifications; (b) signals about a roughly described product; (c) signals about product class; (d) signals about demand for some kind of functions; or (e) no signals whatsoever, even if demands exist. The degree to which these can be determined will have a lot to do with the probabilities that investment will be attracted and that innovation will occur (Teubal et al. 1976). The sending and receiving of signals and the overall influence of demand factors on investment—in this case, investment in medical innovation—is not at all straightforward or linear; on the contrary, it is highly iterative (Gelijns and Pannenborg 1973; Lotz 1993; Mowery and Rosenberg 1982). It is also highly dependent on knowledge about the "owners" of the needs, that is, the "users," their preferences, and the expression of those preferences in patterns of adoption. In this framework, the populations that are germane to conceptualizing the market for the outputs from contraceptive research and development are the population that (a)   has been defined as having an unmet need for family planning, and (b)   has evidenced a desire to actively use contraception in response to that need; and the subset of that population (or some third party) which can—and will—pay for the satisfaction of those needs and desires. Thus, the "market demand" population is always the smallest subpopulation in the set. If it cannot be identified somehow as substantial, there is no incentive for a potential product developer or seller to invest in this particular market. Therefore, from a commercial perspective it is crucial to determine what fraction of the "unmet need" population represents a true market opportunity. Calculating the Unmet Need for Contraceptives Like "demand," "unmet need" is an elusive concept, changing according to how survey questions are posed, what assumptions are made, and the criteria used for exclusion and inclusion (Dixon-Mueller and Germain 1992). All these elements affect quantification of the ultimate size of the population defined as

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--> needing contraceptive protection, as well as estimates of what is needed in the way of services and commodities. The definition of unmet need is surely crucial for computing the market for contraceptive technologies. Over the past 15 years, there have been numerous alternative calculations of the need and demand for contraceptives. The most generally accepted have been those authored by Westoff (e.g., Westoff and Ochoa 1991), which have been enormously useful in defining national family planning policies and prioritizing the need for international assistance. However, these approaches have been revisited recently from a women's health perspective and revised in a way that defines the base population more broadly (Dixon-Mueller and Germain 1992 and 1994; Guttmacher Institute 1995a; Wulf 1995) (see Table 2-1). The rationale for "casting a wider net" is that conventional definitions, which essentially restrict the unmet-need concept to married women1 and nonusers of contraception, respond neither to the contemporary realities of women's (or men's) lives, nor to the statistical realities concerning contraceptive utilization, effectiveness, and appropriateness. The expanded definition adds to the basic conventional definition the following population groups: sexually active, unmarried women; women with postpartum amenorrhea; women who are using a less effective contraceptive method but who definitely want to avoid or postpone childbearing; women who are using a more effective method but who are using it incorrectly, are dissatisfied, or should not be using it for health reasons; women with unwanted pregnancies; and women with related reproductive health problems (Dixon-Mueller and Germain 1994). Both the conventional and expanded definitions can be used to calculate need in national population subgroups by residence, age, and even subculture, and to compare countries in terms of magnitudes and characteristics of need and the ability of women in those countries to realize their reproductive wishes. Nonetheless, the effects of their different premises on calculation of unmet need can be strikingly large in the aggregate, ranging from an estimated 120 million (Ketting 1994; Robey et al. 1992) to 228 million women at risk of unplanned pregnancy even though they do not want to have a child (Guttmacher Institute 1995a). Reproductive Preferences Reproductive preferences have been a routine part of fertility and family planning surveys from their inception, as these surveys have sought to quantify

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--> and measure fertility norms (desired or ideal number of children), reproductive intentions (intentions to postpone or terminate childbearing), spacing intentions (preferred length of the next birth interval), and wanted and unwanted births (intendedness). Reproductive preferences are also integral to defining unmet need. While preference data were for a long time viewed as the "soft" part of demographic surveys, recent methodological research has raised confidence in their predictive validity, although that is variable. For example, using the "ideal" or ''desired" number of children has been thought to lack any particularly predictive utility, because it reflects societal norms more than it truly reflects individual intentionality. However, though there may be some erosion in individual preferences in response to personal, family, or societal pressures (Freedman 1990), the percentage of women who state that they want no more children is a good short-term predictor of fertility rates (Westoff 1991). As such, it is a reasonable indicator for purposes of user-based market analysis, despite the inevitable divergence between the number of children women say they wanted or would want in the future and the number they actually have (the "KAP [knowledge, attitudes, and practices] gap").2 Since there have been some dramatic changes in fertility levels worldwide during the past two decades, it is reasonable to assume that there has been some kind of fit between women's preferences and their actual behavior. The fact that the fit is imperfect does not invalidate the measure. At the same time, even the most meticulously shaped definition of either unmet need or unmet demand omits a number of qualitative variables that are crucial to conceptualizing the market for new contraceptive technologies. Discounting the force of various dimensions of local culture—for example, politics, gender roles, and the values assigned to fertility—and assuming that women everywhere will behave in the same ways given equivalent knowledge, resources, and options, is as risky for calculating a market as it is for implementing family planning programs. Third-Party and Public Health Perspectives Having defined a population with an unmet demand for contraception, it is then possible to address the question of what fraction of that population represents true market demand. As suggested at the beginning of this chapter, there are two very different subpopulations to be accounted for: Subpopulation 1, consisting of those able and willing to spend their own resources; and Subpopulation 2, consisting of those for whom some third party is prepared to pay. This latter, "third-party" category contains considerable variety: private insurance companies, managed care organizations, hybrid network arrangements, and government programs for the poor in the United States and other developed nations, as well as national family planning and public health sector programs in develop-

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--> TABLE 2-1 Comparison of Two Approaches to Calculating Unmet Need for Family Planning   Westoff and Ochoa (1991) AGI (1995) Includes   Population Include as Having an as Having an Unmet Assumptions Underlying Characteristics Unmet Need for Contraception: Need for Contraception: AGI Calculations Union status All women currently in union All women of reproductive age Many single women also have a need to avoid pregnancy Age Aged 15-49 Aged 15-44 Women aged 45-49 are probably infecund in any event Pregnancy All women who did not want most recent pregnancy and were not contracepting at time of that conception All women who do not want current pregnancy, whether or not contracepting at time of that conception Some women are unable to use any method effectively or are using a method with high failure rates Amenorrhea postpartum All women who did not want most recent pregnancy and were not contracepting at the time of that conception All women who do not want another child, soon or ever, and are not using an effective method of contraception All have a need even if, technically, they cannot conceive at the moment Use of postpartum abstinence Women using postpartum abstinence   Although the abstinence may not be intended to prevent pregnancy, it nonetheless has assured contraceptive effect, so that women maintaining postpartum abstinence are not in need Method use   Women using traditional methods of contraception (rhythm, withdrawal, etc.) Traditional methods can have high failure rates and thus do not offer effective protection from unintended pregnancy

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-->   Excludes: Excludes:   Fecundity All women married for at least 5 years, not contracepting, and who have not had a child during that time Only women who themselves say they cannot have a child; women who do not so indicate are defined as "in need" Unless women indicate that they have been infecund during this period, they might actually have conceived during a period assumed to be infecund and then had an abortion Note: "Includes" means that women with these characteristics are included in the pool of women considered to have an unmet need for contraception. "Excludes" means that women with these characteristics are not included in that pool, since either their need is viewed as satisfied or they are not considered at risk of conception. Sources: Alan Guttmacher Institute (AGI). Hopes and Realities: The Gap Between Women's Aspirations and Their Reproductive Experiences. New York: The Alan Guttmacher Institute. 1995. Westoff CF, LH Ochoa. Unmet Need and the Demand for Family Planning. DHS Comparative Studies, No. 5. Columbia, MD: Institute for Resource Development. 1991. Wulf D. The Unmet Demand for Family Planning. Unpublished paper. New York: Rockefeller Foundation, 1995.

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--> ing and industrializing countries, often at least partly subsidized by overseas development assistance. These subpopulations also have slightly different perspectives regarding the "value" or cost-effectiveness of contraception. Individuals, who do not as directly bear some of the broader social costs of increased population size that result from less-than-optimal levels of contraception, give primary emphasis to efficacy, side effects, out-of-pocket costs, and personal concerns such as convenience and autonomy. In contrast, third-party payers are more likely to be sensitive to the costs of unintended pregnancies, in terms of the cost and risks of abortion and the costs and risks of carrying unintended pregnancies to term. In the developing world, there is more heterogeneity in perspectives on family planning and contraception, depending on the history of a given country, its culture and religions, and where it is demographically, economically, and epidemiologically. Some countries, particularly those whose fertility rates remain high, must continue to worry about population growth rates, sizes, and densities. A growing number of other countries, further along in the demographic and epidemiologic transitions, must address both an "unfinished agenda" of high mortality, infectious disease, and malnutrition and a swelling agenda of noncommunicable and chronic diseases in adults and the elderly (Mosley et al. 1993). All countries, sooner or later, will find themselves obliged to somehow add to their priorities the new agenda, articulated at Cairo and ratified at Beijing, relating to the empowerment of women and their reproductive health and rights. The fact that these economies must take into account all these valid and pressing agendas and must do so with persistently constrained health sector resources means that they, like the established market economies and the formerly socialist economies of Europe, are also having to focus hard on issues of cost containment, cost-effectiveness, and cross-sectoral externalities and trade-offs in development investment (World Bank 1993). But here, too-and this is important-individuals have the same concerns and needs as do individuals in developed countries: they do not voluntarily choose to use contraception primarily because of national demographic or macroeconomic concerns. There is a third area where individual and societal health needs coincide because their nature is such that, left unsatisfied, they incur costs of some kind which can be quantified, albeit in different ways. The costs of contraception can then be compared to the costs of nonsatisfaction of these shared individual and public health needs so that, in some cases, it is possible to develop cost-benefit or cost-effectiveness ratios. At a minimum, it is possible (though not necessarily simple) to calculate the various costs of a given case of "nonsatisfaction" to whoever the payer is: the society at large, some third-party payer, or an individual. These shared unmet needs include unintended pregnancy, abortion, maternal mortality and morbidity, and sexually transmitted disease, needs which can be especially acute and especially costly in populations of particular vulnerability owing to such covariates as age, parity, ethnicity, or socioeconomic status.

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--> The societal costs of all of these are high and, in some instances, can only increase, either because the magnitude of the need itself increases, or because it will simply become more expensive to deal with, or both. Contraception offers very cost-effective and risk-reducing alternatives to unwanted pregnancies, whether those pregnancies are terminated by abortion or allowed to go to term, as well as to morbidity (Lee and Stewart 1995; Trussell et al. 1995). At present in the United States, a majority of third-party payers would seem to be missing a major investment by not offering a broad range of contraceptives as a cost-containment strategy that has potential economic payoff well in excess of many other forms of health care. We will argue in Chapter 5 that contraception that includes or is accompanied by protection against sexually transmitted diseases is even more cost-effective and surely risk-reducing. As more and more third-party payers assume long-term responsibility for covering large, stable populations over a long period of time for a broad range of health care services, it is reasonable to assume that they will look to those savings that can be derived from prevention and, therefore, see the economic value and consequent logic of substantially increasing their investment in contraceptive and reproductive health services as a major cost-containment tool. This will not be an overnight process. Ongoing restructuring of the managed care industry and the current mobility of subscribers shopping for the best care at the best price will, for a while, affect the potential for a given HMO to realize a payback from investment in prevention. At the same time, the payback from pregnancy prevention, with its rapid "turnaround" and transparent causal attribution, can be realized much faster than, for instance, the payback from nutrition education and prevention of high-cost chronic diseases. A Life Span Perspective There is a growing constituency in the public health community for a more inclusive and integrative model of individual and family health and well-being, and use of the phrases "life cycle" and "life span" to define a perspective have acquired a certain currency, particularly in connection with women's health and well-being. The basic premise of this perspective is that human health and illness are not a haphazard affair, but express the accumulation of conditions that begin early in life, in some respects before birth. A second premise is that the factors that favor good health and precipitate ill health are not purely genetic or biological but can be social, economic, cultural, and psychological, and can work together or against one another across the span of an individual's life in ways that we are only beginning to understand. The third premise is that no reasonable public health strategy can ignore these dynamics and what constitutes a continuity of risk over an entire lifetime (Institute of Medicine [IOM] 1996; Tinker et al. 1994; UNFPA 1994; World Bank 1994). The importance of the life span concept to this report is straightforward enough: At different points across their life

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--> spans, women have different reproductive intentions, different pressures on their lives, different needs for contraception, and different overall reproductive health requirements. Contraceptive research and development has to take all of these life span dimensions into account since, to a large extent, they shape the structure of demand. In developed countries, the portion of the female life span that can be described as the "potential reproductive years," that is, the years between menarche and menopause, constitutes about half of a woman's total life span; in developing countries, where life expectancies are generally shorter, that portion can be well over half. This means that a typical woman in the United States is at biological risk of pregnancy for approximately 36 years (Hatcher et al. 1994). Fourteen percent of those potential reproductive years (or years at biological risk of pregnancy) is spent in Stage 1, the years between menarche and first intercourse, and 19 percent in Stage 2, the years between first intercourse and marriage; during these two stages, the large majority of women will be trying to avert or postpone pregnancy. Stage 3 comprises the years between marriage and first birth, or 5 percent of the years at risk, during some part of which some women will be averting or postponing pregnancy. Stage 4, the years between first birth and attainment of desired family size, represents 11 percent of the potential reproductive years, during which the emphasis for most women is on spacing births. The years that follow, that is, the years between attainment of desired family size to menopause (Stage 5) occupy 51 percent of the whole span of potential reproductive life. This span of years consists of two periods, the boundary between which is typically blurred except for women who are surgically sterile. The first is the period between the age of intending no more children and presumed3 sterility, during which many women will want to avert pregnancy; the second comprises the years from presumed sterility to menopause, when there is no concern for contraception. Nevertheless, during Stage 5 and into the postmenopausal period (Stage 6), many women will still require protection from sexually transmitted infection, as is increasingly the case for many women throughout their reproductive years (Forrest 1993). For women who want a certain number of children, these proportions change somewhat to account for the years spent in pregnancy, postamenorrheic abstinence or infecundity, or sexual inactivity. The hypothetical woman who is sexually active between ages 20 and 45 and wants two children will need protection from pregnancy for approximately 20 years, that is, 82 percent of her 25-year reproductive life. The woman who wants four children will need protection for about 16 years, or 64 percent of her reproductive life. Even the woman who wants six children will need nearly 12 years of protection, or 46 percent of her reproductive life (see Table 2-2). For women who begin childbearing in their teenage years, these estimates are, of course, conservative. The general rule is that, for all women, everywhere, the younger they are when they begin their reproductive lives, the older they are at menopause; the fewer children they want,

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--> TABLE 2-2 Proportions of Female Reproductive Life During Which Protection from Pregnancy Is Needed Number of Children Wanted by Hypothetical Woman Number of Months Wanting Pregnancy Number of Months Being Pregnant Number of Months Postpartum Protection Number of Months Not Wanting Pregnancy Number of Years Not Wanting Pregnancy % of Total Reproductive Life 2 24 18 12 246 20.5 82.0 4 48 36 24 192 16 64.0 6 72 54 36 138 11.5 46.0 Note: Reproductive life span is hypothesized to be 300 months, or 25 years, from age 20 to age 45. Source: Alan Guttmacher Institute. Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences. New York: The Alan Guttmacher Institute. 1995.

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--> women wanted a smaller family size than did their husbands, although in all the Sub-Saharan African countries women still desired rather large families (see Table 2-15). In this same sample, however, while smaller proportions of husbands than of wives said that they did not want any more children, the differences between husbands and wives in this respect were not very large, ranging from 4 to 9 percentage points (Guttmacher Institute 1995a). The presumption has been that men's limited involvement in contraception is driven by the fundamental gestalt that, in virtually all societies, defines the roles, status, and power of females as inferior and subordinate to those of males. This presumption has, in turn, driven the historical emphasis placed by family planning programs on women, to the virtually a priori exclusion of men (Kabeer 1992; Sachs 1994; Sadik 1995). Except for the Population Council's intramural basic science research program, which has included attention to development of male contraceptives, that presumption has also driven the investment in contraceptive research and development, at least partly because of the view that male interest in being involved in contraceptive use was quite limited in most populations. As a consequence, men did not benefit from the first contraceptive revolution. That view has been something of a self-fulfilling prophecy (Population Reports 1994) and has been tested in only a fragmentary way; most reports on male attitudes toward contraception have come from women. However, as some countries have gathered data on male perceptions of contraception in connection with the Demographic and Health Surveys, there appears to be more heterogeneity in male attitudes than might be expected, even in Africa, where high fertility has deep cultural and socioeconomic roots (UNFPA 1995). At the same time, there is no question that greater male involvement in contraception is a large and commanding need in terms of public health and the well-being of children and the family. The need is no less in the United States, where one in 15 men fathers a child while he is a teenager (Marsiglio 1987) and where attention is now being given to the possibility of expanding family planning clinic services to men (Burt et al. 1994). The rationales include the need to include male partners in STD testing, treatment, and education; adding services for men as part of managed care marketing strategies; and the national emphasis on male responsibility in welfare and child support enforcement programs, an integral part of every welfare reform program currently under consideration by the U.S. Congress (Schulte and Sonenstein 1995). The topic of male participation in contraception is taken up in more detail in the next chapter in connection with the use of male methods and the market for contraceptives. Concluding Comment At the outset of this chapter, "needs" were defined as "a state of felt depriva-

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--> TABLE 2-13 Husbands' Involvement in Family Planning Decisions (selected countries) Country and Survey Year No. of Intervieweesa % Who Know of at Least One Method % Approving of Family Planning (FP) % Who Have Discussed FP with Their Wives in the Last Yearb % Who Have Ever Used Contraception % Currently Using Contraception % Family Member Deciding Modern Any Modern Any W H J Burundi, 1987 542 92 94 48 2 52 NA NA — — — Cameroon, 1991 814 74 37 30 17 48 6 20 — — — Egypt, 1988-1989 9,000 (women) — — — — — — — 14 25 61 Cairo 469 100 92 61 78 81 65 70 — — — Upper Egypt 1,053 96 84 47 52 56 40 44 4 59 36 Ghana, 1988 943 79 77 46 26 41 9 20 — — — India, 1986 (rural) 250 (women) — — — — — — — 4 24 38d Kenya, 1989 1,170 95 91 65 35 65 25 49 — — —

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--> Mali, 1987c 970 65 16 28 2 16 1 4 — — — Morocco, 1992 — — — 47 — — — — — — — Niger, 1992 — — — 11 — — — — — — — Pakistan, 1990-91 1,354 79 56 14 18 25 10 15 — — — Turkey, 1991                       Semi-urban (women) 366 — — — — — — — 62 8 25 Rural (women) 358 — — — — — — — 29 23 46 Note: NA = not applicable; W = wife, H = husband, J = joint. a Husbands, except where otherwise noted. b Among those who knew at least one contraceptive method. c Includes all men, regardless of marital status. d 22 percent of the family planning decisions in rural India in this survey were made by the extended family. Sources: Derived from tables in McCauley AP, B Robey, AK Blanc, JS Geller, Opportunities for women through reproductive choice, Population Reports, Series M, No.12, July 1994. Data for Morocco and Niger are from Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences, New York, The Alan Guttmacher Institute, 1995.

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--> TABLE 2-14 Women's Discussion of Family Planning with Their Husbands (selected countries) Country and Survey Year % Using Family Planning Among Those Who: Discussed with Husband Did Not Discuss with Husband Botswana, 1988 40 18 Burundi, 1987 14 2 Ghana, 1988 24 7 Kenya, 1986 36 11 Senegal, 1986 23 9 Sudan, 1989-1990 19 3 Togo, 1988 39 31   Source: Based on graphics in Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences, New York, The Alan Guttmacher Institute, 1995 (based on data from Demographic and Health Survey country reports, with special tabulations of the data files for Pakistan). tion of some basic satisfaction." We have spoken about the general areas of need that have to do with societal and individual health and options and that make contraception a commanding issue for societies and individuals who wish to use it. We have also indicated that, beyond these general areas of need, there are very specific needs for new technologies that are not now being satisfied adequately. A new approach to estimating the overall unmet need for contraception identifies somewhere around 228 million women worldwide (not men, whose needs must also be taken into separate account) who can fairly be said to be in need of contraception. Overwhelming majorities of women want to control their fertility, even in Sub-Saharan Africa with its traditionally high value accorded to large families. And very large numbers of women, even those who have not yet achieved their desired family size, nonetheless state that they failed in their intentions with regard to their last pregnancy, either because they did not mean to have it at all or because they meant to have it at some later date. Another dimension of general need is the sheer number of years women require protection from unintended pregnancy since, somewhat ironically, as completed family size continues to fall worldwide, women's lifetime exposure increases; a woman who wants only two children will require 20 years of protec-

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--> TABLE 2-15 Male Perspectives on Desired Family Size   Desired Family Size % Wanting No More Children Country Husbands Wives Husbands Wives Niger 12.6 8.5 2 9 Cameroon 11.2 7.3 10 14 Tanzania 7.4 6.4 17 23 Burundi 5.5 5.5 — — Ghana 6.6 5.5 19 23 Pakistan 5.4 5.3 33 40 Morocco 4.1 3.9 43 52 Kenya 4.1 3.9 44 52 Egypt 3.3 2.8 61 67   Source: Based on graphics in Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences. New York: The Alan Guttmacher Institute. 1995 (based on data from Demographic and Health Survey country reports, with special tabulations of the data files for Pakistan). tion from that exposure. This means that, for a number of reasons, the same contraceptive is unlikely to be appropriate for an ever-longer and more biologically various life span, thus requiring a more various set of contraceptive alternatives. Ancillary analyses tell us about other aspects of the general need for contraception. These include the women all over the world, still in their teens, whose physical well-being and life chances are at special risk: young women spending longer periods of time before entering into formal union, with a greater amount of sexual activity than seems to have been the case in the past; young women following tradition and continuing to enter union very early; and those young women of whom one-quarter to one-half are having their first child before any formal union. These are not exclusively Third World phenomena: In 1987, 1.2 million pregnancies occurred in the United States among women under 20, almost all of which were resolved outside marriage, with about half of those terminating in abortion. This is, of course, part of a bigger picture: The 1995 projection for the number of abortions worldwide is 52 million-28 percent of the 139 million live births projected for this year-about 21 million of which will be performed in countries where they are illegal and, presumably, unsafe. If so

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--> many women are resolving their pregnancies in this fashion, one must assume they need contraceptive help. In Chapter 5 we will focus on those specific areas that point to a need for new contraceptive technologies, not only because they expand the range of contraceptive options overall, in itself a compelling need, but because they fill needs that are not now being met adequately. These include the need for contraceptives suitable for women who have been exposed to unprotected sexual intercourse, contraceptives with anti-infective properties, and methods for men. References Alan Guttmacher Institute. Hopes and Realities: The Gap Between Women's Aspirations and Their Reproductive Experiences. New York: The Alan Guttmacher Institute. 1995a. Alan Guttmacher Institute. Women, Families, and the Future: Sexual Relationships and Marriage Worldwide (Fact Sheet). New York: The Alan Guttmacher Institute. 1995b. Alexander, NJ. Sexual transmission of human immunodeficiency virus: Virus entry into the male and female genital tract. Fertility and Sterility 54(1): 1-18, 1990. Aral SO, ME Guinan. Women and sexually transmitted diseases. IN Sexually Transmitted Diseases. KK Holmes, P-A Mardh, PF Sparling, PJ Wiesner, eds. New York: McGraw-Hill. 1984. Brandrup-Lukunow A. Family Planning and Reproductive Health in CCEE/NIS: Background Paper for ECO/UNFPA Conference on Women's Status and Health. Copenhagen: WHO-EURO. 1995. Brunham RC, JE Embree. Sexually transmitted diseases: Current and future dimensions of the problem in the Third World. IN Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health. A Germain, KK Holmes, P Piot, JN Wasserheit, eds. New York: Plenum. 1992. Burt MR, LY Aron, LR Schack. Family Planning Clinics: Current Status and Recent Changes in Services, Clients, Staffing, and Income Sources-Report to The Henry J. Kaiser Family Foundation. Washington, DC: The Urban Institute. 1994. Cates W Jr, KM Stone. Family planning: The responsibility to prevent both pregnancy and reproductive tract infection. IN Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health. A Germain, KK Holmes, P Piot, JN Wasserheit, eds. New York: Plenum. 1992. Chen L, J Sepulveda, S Segal, eds. AIDS and Women's Health: Science for Policy and Action. New York: Plenum. 1992. Chen V. A new social norm: All pregnancies intended. Carnegie Quarterly, Fall 1994-Winter 1995:10-11, 1995. Claypool LE. The challenges ahead: Implications of STDs/AIDS for contraceptive research. IN Contraceptive Research and Development 1954 to 1994: The Road from Mexico City to Cairo and Beyond. PFA Van Look , G Pérez-Palacios, eds. Delhi: Oxford University Press. 1994. Dixon-Mueller R, A Germain. Unmet need from a woman's health perspective. Planned Parenthood Challenges 1:9-12, 1994. Dixon-Mueller R, A Germain. Stalking the elusive "unmet need" for family planning. Studies in Family Planning 23(5):330-335, 1992. Fathalla M. Reproductive health in the world: Two decades of progress and the challenge ahead. IN Reproductive Health: A Key to a Brighter Future, J Khanna et al., eds. Geneva: World Health Organization. 1992.

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--> Forrest JD. Epidemiology of unintended pregnancy and contraceptive use. American Journal of Obstetrics and Gynecology 170(5, Part 2):1485-1489, 1994. Forrest JD. Timing of reproductive life stages. Obstetrics and Gynecology 82(1):105-111, 1993. Fortney JA. Contraception—A lifelong perspective. IN Dying for Love: New Perspectives on Human Reproduction. Washington, DC: National Council for International Health. 1989. Freedman R. Family planning programs in the Third World. Annals of the American Academy of Political Science 510:41, 1990. Gelijns AC, CO Pannenborg. The development of contraceptive technology: Case studies of incentives and disincentives to innovation. International Journal of Technology Assessment 9(2):210-232, 1993. Germain A, KK Holmes, P Piot, JN Wasserheit, eds. Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health. New York: Plenum. 1992. Geronimus AT. Teenage childbearing and social disadvantage—Unprotected discourse. Family Relations 41:244-248, 1992. Geronimus AT, S Korenman. The socioeconomic costs of teenage childbearing: Evidence and interpretation. Demography 30(2):281-296, 1993. Geronimus AT, S Korenman. The socioeconomic consequences of teen childbearing reconsidered. Quarterly Journal of Economics 107:1187-1214, 1992. Guttmacher Institute. See Alan Guttmacher Institute. Gwinn M, M Pappaioanou, JR George, et al. Prevalence of HIV infection in childbearing women in the United States. Journal of the American Medical Association 265(13): 1704-1708, 1991. Hatcher RA, J Trussell, F Stewart, et al. Contraceptive Technology: 16th Revised Edition. New York: Irvington Publishers. 1994. Henshaw SK. Induced abortion: A world view, 1990. Family Planning Perspectives 22:76-89, 1990. Henshaw SK, JD Forrest. Women at Risk of Unintended Pregnancy, 1990 Estimates: The Need for Family Planning Services, Each State and County. New York: The Alan Guttmacher Institute, 1993. Henshaw SK, J Van Vort. Abortion services in the United States, 1991 and 1992. Family Planning Perspectives 26:100-106, 1993. Herz B, AR Measham. The Safe Motherhood Initiative: Proposals for Action. Discussion Paper No. 9. Washington, DC: World Bank. 1987. Hoffman SD, EM Foster, FF Furstenberg Jr. Revaluating the costs of teenage childbearing: Response to Geronimus and Korenman. Demography 30:291-296, 1993. Institute of Medicine (IOM). In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa . M Law, CP Howson, PF Harrison, D Hotra, eds. Washington, DC: National Academy Press. 1996. IOM. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. S Brown and L Eisenberg, eds. Washington, DC: National Academy Press. 1995. IOM. Emerging Infections: Microbial Threats to Health in the United States. J Lederberg, RE Shope, SC Oaks Jr, eds. Washington, DC: National Academy Press. 1992. Kabeer N. From Fertility Reduction to Reproductive Choice: Gender Perspectives on Family Planning. Institute of Development Studies Discussion Paper 299. Brighton, UK: University of Sussex. 1992. Kaiser/Harris. National Survey Results on Public Knowledge of Abortion Rates. Menlo Park, CA: The Henry J. Kaiser Family Foundation. January 1995. Ketting E. Global unmet need: Present and future. Planned Parenthood Challenges 1:31-34, 1994b. King TM, JB Smith. From menarche to menopause: The contraceptive transition. IN Contraceptive Research and Development 1984 to 1994: The Road from Mexico City to Cairo and Beyond. PFA Van Look, G Pérez-Palacios, eds. Geneva: World Health Organization. 1994.

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--> Koonin LM, JC Smith, et al. Abortion surveillance—United States. Mortality and Morbidity Weekly Report I (SS-5):1-33, 1992. Kotler P. Marketing Management. Englewood Cliffs, NJ: Prentice Hall. 1988. Kubicka I, Z Matejcek et al. Prague children from unwanted pregnancies revisited at age thirty. Submitted for publication, 1994, cited in The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. S Brown, L Eisenberg, eds. Washington, DC: National Academy Press. 1995. Kwast BE, RW Rochat, W Kidane-Mariam. Maternal mortality in Addis Ababa, Ethiopia. Studies in Family Planning 17:288-301, 1986. Laga M. Human immunodeficiency virus infection prevention: The need for complementary STD control. IN Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health. A Germain, KK Holmes, P Piot, JN Wasserheit, eds. New York: Plenum. 1992. Larson A. Social context of human immunodeficiency virus transmission in Africa: Historical and cultural bases of East and Central African sexual relations . Review of Infectious Diseases 11:716-724, 1989. Lee PR, FH Stewart. Failing to prevent unintended pregnancy is costly. (Editorial). American Journal of Public Health 85(4):479-480, 1995. Lotz P. Demand as a driving force in medical innovation. International Journal of Technology Assessment 9(2):174-188, 1993. Luker K. Dubious conceptions: The controversy over teen pregnancy. American Prospective, 1991: 73-83, 1991. Marsiglio W. Adolescent fathers in the United States: Their initial living arrangements, marital experience, and educational outcomes. Family Planning Perspectives 19(6):240-251, 1987. McCauley AP, B Robey, AK Blanc, JS Geller. Opportunities for women through reproductive choice. Population Reports, Series M, No. 12 (Special topics), July 1994. Meheus A. Women's health: Importance of reproductive tract infections, pelvic inflammatory disease and cervical cancer. IN Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health. A Germain, KK Holmes, P Piot, JN Wasserheit, eds. New York: Plenum. 1992. Mosley WH, JL Bobadilla, DT Jamison. The health transition: Implications for health policy in developing countries. IN Disease Control Priorities in the Developing World. DT Jamison, WH Mosley, AR Measham, JL Bobadilla, eds. New York: Oxford University Press. 1993. Mowery DC, N Rosenberg. The influence of market demand upon innovation: A critical review of some recent empirical studies. IN Inside the Black Box: Technology and Economics. N Rosenberg, ed. Cambridge, MA: Cambridge University Press. 1982. Nelson RR, SG Winger. In search of a useful theory of innovation. Research Policy 6:36-76, 1977. Over M, P Piot. HIV infection and sexually transmitted diseases. IN Disease Control Priorities in the Developing World. DT Jamison, WH Mosley, AR Measham, JL Bobadilla, eds. New York: Oxford University Press. 1993. Population Reports. Opportunities for Women Through Reproductive Choice. Series M, No. 12, July 1994. Robey B, SO Rutstein, L Morris, R Blackburn. The reproductive revolution: New survey findings. Population Reports, Series M. No. 11. Baltimore: Johns Hopkins School of Public Health, Population Information Program. 1992. Rosenfield A. Maternal mortality in developing countries: An ongoing but neglected epidemic. Journal of the American Medical Association 262(3):376-379, 1989. Rosenfield A, D Maine. Maternal mortality—A neglected tragedy: Where is the M in MCH? Lancet, 13 July: 83-85, 1985. Sachs A. Men, sex, and parenthood. World Watch, March-April: 12-19, 1994.

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--> Sadik N. The State of World Population 1995—Decisions for Development: Women, Empowerment and Reproductive Health. New York: United Nations Population Fund. 1995. Stein Z. HIV prevention: The need for methods women can use. American Journal of Public Health 80:460-462, 1990. Teubal M, N Arnon, M Trachtenberg. Performance in innovation in the Israeli electronics industry: A case study of biomedical electronics instrumentation. Research Policy 5:354-379, 1976. Tinker A, P Daly, C Green, et al. Women's Health and Nutrition: Making a Difference. Discussion Paper 246. Washington, DC: World Bank. 1994. Trussell J, J Koenig, C Ellertson, F Stewart. Emergency Contraception: A Cost-Effective Approach to Preventing Unintended Pregnancy. Unpublished manuscript. Princeton, NJ: Office of Population Research. November 1995. United Nations Population Fund (UNFPA). Programme Advisory Note: Male Involvement in Reproductive Health. New York: UNFPA. 1995. UNFPA. Programme of Action of the United Nations International Conference on Population and Development. Cairo and New York: UNFPA. 1994. Walsh JA, CM Feifer, et al. Maternal and perinatal health. IN Disease Control Priorities in Developing Countries. DT Jamison, WH Mosley et al., eds. New York: Oxford University Press. 1993. Wasserheit, JN. Epidemiological synergy: Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. IN AIDS and Women's Health: Science for Policy and Action. L Chen, J Sepulveda, S Segal, eds. New York: Plenum. 1992. Wasserheit JN, KK Holmes. Reproductive tract infections: Challenges for international health policy, programs, and research. IN Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health. A Germain, KK Holmes, P Piot, JN Wasserheit, eds. New York: Plenum. 1992. Westoff CF. Reproductive Preferences: A Comparative View. Demographic and Health Surveys, Comparative Studies, No. 3. Columbia, MD: Institute for Resource Development. 1991. Westoff CF, LH Ochoa. Unmet Need and the Demand for Family Planning. Demographic and Health Surveys, Comparative Studies, No. 5. Columbia, MD: Institute for Resource Development. 1991. Williams LB, WF Pratt. Wanted and unwanted childbearing in the United States: 1973-1988. Advance data from Vital and Health Statistics, No. 189. Hyattsville, MD: National Center for Health Statistics. 1990. World Bank. A New Agenda for Women's Health and Nutrition. Washington, DC: World Bank. 1994. World Bank. World Development Report 1993: Investing in Health. New York: Oxford University Press. 1993. World Health Organization (WHO). Maternal mortality and morbidity. IN 1996 World Population Monitoring Report (draft version). New York: United Nations Population Fund, Population Division. 1996. WHO. Abortion: A Tabulation of Available Data on the Frequency and Mortality of Unsafe Abortion, 2nd ed. Geneva: Division of Family Health, World Health Organization. 1994. WHO. Maternal Mortality: A Global Factbook. Geneva: World Health Organization. 1991. WHO. Prevention of Maternal Mortality: Report of a WHO Interregional Meeting, Geneva, 11-15 November 1985. Mimeo. Geneva: World Health Organization. 1986. Wulf D. The Unmet Demand for Family Planning. Unpublished manuscript. New York: The Rockefeller Foundation. 1995.

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--> Notes 1.   The term ''married" as used in this report includes marriages approved by civil, religious, or other customary practices; cohabiting and consensual unions that are socially recognized; and visiting unions where those are recognized. 2.   The "KAP-gap" is defined as an inconsistency between a woman's stated childbearing preference and her practice of birth control as ascertained from surveys of her knowledge, attitudes, and practices (KAP) such as the World Fertility, Contraceptive Prevalence, and the Demographic and Health Surveys. Dixon-Mueller and Germain (1992) distinguish between a "conventional" KAP-gap which refers to women who say they want no more children but are not practicing contraception, and an "instantaneous" KAP-gap, which refers to women who say they want no more children or who want to postpone the next pregnancy, are exposed to the risk of pregnancy, and are not practicing contraception. 3.   "Presumed" refers to the fact that it is not absolutely guaranteed that no unintended pregnancy will not occur. 4.   Some analysts (Geronimus 1992; Luker 1991) argue that the negative effects of early childbearing may reflect the disadvantaged backgrounds of those adolescents who become parents rather than the timing of the birth itself. Recent analyses of large U.S. national data sets do, in fact, suggest that the negative socioeconomic effects of teenage childbearing are diminished when the mother's prepregnancy characteristics and within- and across-family heterogeneity are taken into account (Hoffman et al. 1993; Geronimus and Korenman 1992 and 1993). Still, so far at least, most researchers using varied approaches and data sets conclude that early childbearing is causally associated with negative outcomes over and above the effects of background (IOM 1995), an association that is much more powerfully true in the developing world (IOM 1996). 5.   The National Survey of Family Growth (NSFG) is the most comprehensive source of information available on pregnancy and contraceptive use among reproductive-age women (15-44 years) in the United States. Conducted by the National Center for Health Statistics (NCHS), the survey is federally funded. Surveys were carried out in 1973, 1976, 1982, and 1988; respondents from the 1988 survey were briefly re-interviewed by telephone. The 1973 and 1976 samples were restricted to ever-married women, among whom most childbearing in the country had occurred. In 1982 and 1988, women of all marital statuses were included. The next round of the NSFG was conducted in 1995 and the data are being processed and analyzed. It has been designed to improve abortion reporting, clarify questions on unwanted and mistimed pregnancies, measure women's ambivalent feelings about becoming pregnant, and improve understanding of unplanned pregnancies through better measures of contraceptive use. 6.   Women "at risk" of unintended pregnancy are defined as those who (a) have had sexual intercourse; (b) are fertile, that is, neither they nor their partners have been contraceptively sterilized and they do not believe that they are infertile for any other reason; and (c) are neither intentionally pregnant nor have they been trying to become pregnant during any part of the year (Henshaw and Forrest 1993). 7.   The sections of this report dealing with unintended pregnancy have relied heavily on the exhaustive analysis of the Demographic and Health Surveys and other national surveys by The Alan Guttmacher Institute, partly in preparation for its recently released study, Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences (1995). Where this is not the case or where a different analytic approach is taken to the Appendix Tables in that report, that is so indicated. 8.   According to the World Health Organization, "Data on abortion in general and unsafe abortion in particular are scarce and inevitably unreliable because of legal and ethical/moral constraints which hinder data collection. Under-reporting and mis-reporting are common because women may be reluctant to admit to an induced abortion, especially when it is illegal. Few studies have achieved higher than 75 percent accuracy of reporting and, in some cases, only a quarter of abortions known to have been performed have been admitted to by respondents. In a rare follow-up study of 118 women

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-->     admitting only to spontaneous abortion in Mérida, Mexico, in 1979, 77 percent later admitted that the abortion had been induced" (WHO 1994). Nevertheless, the WHO document from which this citation was taken is as thorough and recent a compendium as exists anywhere and should be considered definitive at this point in time. Still, as the document itself indicates, the numbers provided, especially the numbers of unsafe abortions, should be considered undercounts. This is so even in the United States. 9.   This figure supersedes a prior estimate of 200,000 generated from projections based on hospital records. Three factors should be taken into account in interpreting this number: The possibility of a concomitant underestimate in rural areas owing to under-reporting; the difficulty of distinguishing primary from secondary causes of death; and, most importantly, its direct relation with the total number of annual maternal deaths (WHO/FHE, personal communication, November 1995). 10.   The term "comparable market economies" refers to selected European countries and Canada. China, the former Soviet Union and newly independent states of central Europe, and most developing countries report ratios to live births that are significantly higher than those in either the United States or other economically comparable countries (Institute of Medicine 1995). 11.   The term "rate" has been traditionally used for this figure; it is, however, really a ratio and measures obstetric risk . 12.   However, the largest absolute number of maternal deaths actually occur among low-risk women, since there are so many more low-risk pregnancies altogether, and because the complications of pregnancy, which also occur among low-risk women, cannot be predicted in advance. 13.   The reproductive tract infections (RTIs) have been broadly defined to include sexually transmitted infections and infections that are nonsexually transmitted, and comprise three types of infection: (1) sexually transmitted diseases (STDs), such as chlamydial infection, gonorrhea, trichomoniasis (which may or may not be sexually transmissible), syphilis, chancroid, genital herpes, genital warts, and human immunodeficiency virus (HIV) infection; (2) endogenous infections, caused by overgrowth of organisms that can be present in the genital tract of a healthy woman, such as bacterial vaginosis and vulvovaginal candidiasis; and (3) iatrogenic infections, associated with medical procedures, such as female genital mutilation, poor delivery practices, cesarean section, unsafe abortion, and improperly performed pelvic examinations and IUD insertions (Brunham and Embree 1992; Meheus 1992). Of the three types of reproductive tract infections—sexually transmitted, endogenous, and iatrogenic—the majority are sexually transmitted in direct fashion (Brunham and Embree 1992). However, the iatrogenic infections are also important because they are linked to contraception, or the lack of contraception, through sepsis during the medical procedures cited above. Of the eight major STD pathogens producing RTIs, four are bacterial (chancroid, chlamydia, gonorrhea, and syphilis) and four are viral (HIV, human papilloma virus/HPV, herpes simplex type 2/ HSV-2, and hepatitis B/HBV). 14.   In the context of the sexually transmitted reproductive tract infections, it is unfortunately necessary at times to use the term "females" rather than "women." Normally, one would expect only women of fertile age to be at risk of such infection. However, rape and other sexual abuse of prepubescent females, as well as female genital mutilation where that is practiced, mean that it is sometimes the case that females—not women-—come to bear a burden of sexually transmitted disease. 15.   It is important to note in this context the behaviorally and biomedically significant distinction between abstinence for pregnancy prevention and abstinence for STD prevention: While the former implies only avoiding penis-in-vagina intercourse, the latter implies avoiding vaginal, anal, and oral intercourse. 16.   Clinical trials of the protection provided by the female condom against sexually transmitted infections are now in progress, under the aegis of the National Institute of Child Health and Human Development of the U.S. National Institutes of Health.