The proportion of reproductive-age married women who use a modern or traditional contraceptive method rose from 55% to 63% between 1990 and 2010, according to a global analysis.1 Most of the increase was due to a 10–percentage-point rise in contraceptive prevalence in the developing world, although contraceptive use also increased in developed countries. The proportion of married women with an unmet need for family planning declined from 15% to 12% worldwide, but remained above 25% in 42 countries, most of them in Africa. Overall, 146 million married women had an unmet need for family planning in 2010—131 million in the developing world and 15 million in developed countries.
To estimate contraceptive prevalence and unmet need among women aged 15–49 who were married (or in a cohabiting union), the researchers developed statistical models that incorporated data from Demographic and Health Surveys, Multiple Indicator Cluster Surveys, Reproductive Health Surveys and other nationally representative household surveys. Analyses incorporated 930 observations of contraceptive prevalence for 194 countries, and 306 observations of unmet need for 111 countries. For each country (and related region and subregion), the investigators estimated contraceptive prevalence and unmet need for family planning for every year from 1990 to 2010 and made projections to 2015. They modeled contraceptive prevalence with a logistic growth curve and unmet need for family planning as a function of contraceptive prevalence. Country-specific estimates and projections were created using a Bayesian hierarchical model that drew not only on observations for the country of interest but also on subregional, regional, and global information. In addition, the model took into account differences among survey observations in the measurement of contraceptive prevalence and the population group represented. The researchers calculated uncertainty intervals for all estimates and projections to enable assessment of whether changes over time were statistically significant.
The analyses revealed that between 1990 and 2010, contraceptive prevalence among married women of reproductive age increased from 55% to 63%. Most of this change was driven by a 10–percentage-point rise in prevalence (from 52% to 62%) in developing countries. In developed countries, the prevalence increased by three percentage points, from 68% to 71%. Prevalence increased faster during the 1990s than during the subsequent decade, both globally and in developing countries. In 2010, at least two-thirds of married women of reproductive age were using contraceptives in North America (77%), Latin America and the Caribbean (73%), Europe (72%) and Asia (67%); however, only three in 10 African women (31%) were doing so.
Regionally, the rise in contraceptive prevalence was greatest in Africa (14 percentage points), Latin America and the Caribbean (12 points) and Asia (10 points). Gains were smaller in North America (5 points) and Europe (4 points), the two regions where prevalence had been highest in 1990. Although increases tended to be greatest when baseline prevalence was lowest, this was not always the case; for example, in 1990, the prevalence in Oceania (60%) was similar to that in Latin America and the Caribbean (62%), but while prevalence rose substantially in the latter region, it showed no change in the former.
Similarly, prevalence and related gains often varied widely within regions. In Africa, substantial increases occurred in the Eastern (21 percentage points), Southern (16 points), and Northern (16 points) subregions, but gains were smaller (7–8 points) in Middle and Western Africa, the two subregions where prevalence had been lowest in 1990. Prevalence increased by at least 10 points in four of the five subregions in Asia; the exception was Eastern Asia, which had the highest prevalence in the world in both 1990 (77%) and 2010 (83%). In Europe, prevalence increased by eight and four percentage points in the Eastern and Northern subregions, respectively, but showed no meaningful change in the Southern and Western subregions.
Overall, prevalence increased by a statistically significant degree in 81 of the 194 countries. In absolute terms, increases in prevalence were greatest in Bhutan (50 percentage points), Cambodia and Swaziland (41 points each), Oman (35 points), and Malawi, Cape Verde and Iraq (33 points each). In 1990, prevalence had been less than 10% in 26 countries; by 2010, it remained under that threshold in only four: Chad, Mali, Sierra Leone and South Sudan. At the other end of the spectrum, the number of countries in which more than 80% of married women of reproductive age were using contraceptives increased from three to six (China, Costa Rica, Hong Kong, Malta, Norway and the United Kingdom). Only one country (Togo) had a statistically significant decline in prevalence.
As contraceptive use increased globally, levels of unmet need fell. Between 1990 and 2010, the proportion of reproductive-age married women who had an unmet need for family planning (either modern or traditional) declined from 15% to 12%. Nonetheless, the proportion with unmet need remained above 25% in three subregions (Eastern, Middle and Western Africa) and 42 countries (29 of them in Africa). One subregion (Eastern Asia) and four countries (China, Malta, United Kingdom and Costa Rica) had a level below 5%.
The decline in unmet need, as with the increase in contraceptive use, was greater in developing countries (from 17% to 13%) than in developed areas (from 11% to 9%). The subregions with the greatest declines in unmet need were Central America (from 21% to 12%), Northern Africa (from 24% to 15%), Southern Africa (from 22% to 14%) and Southern Asia (from 22% to 15%). In many other areas, such as Middle Africa, Western Africa, Southern Europe, Western Europe, North America and Oceania, little or no change occurred. Europe had a small decline (two percentage points).
Worldwide, 146 million married women of reproductive age had an unmet need for family planning in 2010, and 221 million had an unmet need for modern methods. Because of population growth, the researchers estimate that by 2015 these numbers will increase to 153 million and 233 million, respectively. The vast majority of these women are in the developing world; in 2010, for example, 131 million married women in developing countries and 15 million in developed ones had an unmet need for any method.
One limitation of the study, the authors note, is the focus on women who were married or in a union, though the researchers add that their methodology can be used to generate estimates and projections for all women. A general challenge for measuring family planning trends is the lack of data on unmet need. In this study, data on unmet need were unavailable for 83 countries; although their models provide "reasonable estimates" for these countries, the authors caution that "substantial uncertainty" surrounds the results. Nonetheless, they emphasize that their estimates can serve as a yardstick for tracking progress in local and global efforts to promote and provide family planning, such as the pledge made by participants at the 2012 London Summit on Family Planning to provide modern contraceptive methods to 120 million women in 69 of the world’s poorest countries.—P. Doskoch
REFERENCE
1. Alkema L et al., National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis, Lancet, 2013, 381(9878):1642–1652.