Lack of access to modern contraception is an issue for countless women and couples in the United States and around the world. But what about when physical and financial barriers to access aren’t the only problem? What about personal, educational, and cultural barriers? Studies show that these types of obstacles may be equally responsible for the high prevalence of unintended pregnancies we see today—six decades after the introduction of the birth control pill.
Barriers in the Developing World
The 214 million women in the developing world who have an unmet need for family planning account for 82 percent of the 80 million unintended pregnancies that occur there each year. The remaining 18 percent are due to inconsistent method use or method failure. If every woman in the developing world with an unmet need for family planning began using a modern method of contraception, the number of unintended pregnancies each year would decline by 71 percent.
The reasons women in the developing world give for not using contraception are not necessarily what one would expect. In one survey of women in Southeast Asia, South Central Asia, and sub-Saharan Africa, women who would like to avoid pregnancy but are not using modern contraception gave the following explanations: 23 percent were concerned about health risks or side effects; 21 percent had sex infrequently; 17 percent were postpartum or breastfeeding; 16 percent were opposed; 10 percent faced opposition from their partners or others; 4 percent were unaware of the methods available to them; and 2 percent believed they were infertile. Only 8 percent of women gave lack of access or high cost as their primary reason for not using modern methods.
|A woman has an unmet need for family planning if she is fertile, sexually active, and does not want to have a child in the next two years but is not using a method of modern contraception.|
Women’s reasons for not using contraception have changed over time. In the late 1980s, a survey of women not using contraception indicated that most were unaware of existing family planning services. Today, that response is uncommon. Now, many women and their partners are concerned about health and potential side effects. In the small Filipino village of Ubay, Generio Apolona is reluctant for his wife Lydia to use contraceptives after hearing about side effects from others in the community. “If Lydia were to get sick, especially while the children are still young…I don’t know what I would do.”
The proportion of women who are personally opposed to contraception or face opposition from their partners suggests that misinformation and cultural barriers must be addressed. According to the Guttmacher Institute, “Such barriers include women’s low level of decision making power within families, differences in fertility preferences between partners, and the stigma attached to unmarried women’s sexual activity and use of contraceptive services.”
|GOMBA DISTRICT, UGANDA – AUGUST 2016 – Prossy Namukwaya, with her husband, Abdu Nasuba, and children, stands in front of their two-room house. Prossy has planted eucalyptus seedlings to try to augment the family income so she can afford to keep her kids in school. PHOTO: Howard LaFranchi/The Christian Science Monitor|
Barriers in the United States
Half (49 percent) of the pregnancies in the United States (and 37 percent of the births) each year are unintended. Most of these are simply mistimed (they would have been wanted at a later date), but a large number of them are unwanted regardless of timing.
Under the prevailing definition, 7.3 percent of American women have an unmet need for family planning. These 4.5 million women account for a large proportion of unintended pregnancies; the rest are due to inconsistent method use or method failure.
American women with unmet need give many reasons for not using contraception—most of which have little to do with affordability or physical access. Among women in a nationally representative survey who did not use contraception before a recent unintended birth, 35.9 percent did not believe that they could get pregnant; 23.1 percent didn’t really mind if they got pregnant; 17.3 percent didn’t expect to have sex; 14.3 percent were worried about side effects; 8 percent had male partners who didn’t want to use birth control themselves; and 5.3 percent had male partners who didn’t want them to use birth control (respondents could give more than one reason).
The policy implication is clear: sex education, including discussion of fertility and contraceptives, must become a priority in this country if our unintended pregnancy rate is to decrease to an acceptable level. A shocking percentage of women are misinformed about their own fertility and ability to conceive. “It seems strange that so many women think they are infertile,” says Amanda Marcotte. “But looking at the combination of social silence on the topic of contraception and a pop culture that portrays people having contraception-free sex with relatively few pregnancies makes it easier to understand.”
Many women (and their partners) are more afraid of the potential side effects of birth control than they are of having an unintended pregnancy. While some women believe myths they’ve heard about side effects, such as increased risk of cancer or diminished future fertility, many have had real experience with mild to severe side effects. In the above referenced study, 30 percent of women who had ever used the pill had discontinued its use. Of those 30 percent, 64 percent gave side effects as the main reason for stopping. Cost and problems with access were also given as reasons for discontinuation, albeit to a lesser degree. The survey showed that women often stopped using a method and didn’t switch to a different one—instead, they went without any protection at all.
Even among women who do use contraception, incorrect use is prevalent. In one survey, 38 percent of women who use the birth control pill reported that they had missed at least one active pill in the last three months. Of those relying on condoms, only 51 percent had used one every time they had sex in the last three months.
Better contraceptive counseling by health providers throughout women’s reproductive lives would help them choose the best method for their changing needs. Single women are apt to want a different method than married women who are open to a pregnancy in the near term—there is new evidence that women who aren’t ready to start families are more receptive to long-acting methods (IUD and implant) when they are properly counseled. Women who have finished childbearing tend to want more long-acting or permanent methods than women who have not yet completed their families.
In a survey of young adults (18-29 years old), respondents’ intention to avoid pregnancy did not match their commitment to using contraception. Part of the problem was ignorance about the various methods available—this is, after all, the generation of young people who grew up with abstinence-only education. For example, 63 percent of respondents said they knew “little or nothing” about birth control pills and 30 percent said they know little or nothing about condoms. Many survey respondents repeated myths they’d heard about side effects of methods like the pill. In fact, the study found that 27 percent of unmarried young women believe that it is “extremely or quite likely that using birth control pills or other hormonal methods of contraception for a long period of time will lead to a serious health problem like cancer.” Many young adults incorrectly believed that contraception is not very effective. And many (59 percent of young women and 47 percent of young men) believed that they are infertile anyway—in actuality, only 8.4 percent of young people are infertile. Only 42 percent said that they consult a professional source like a nurse or doctor for information about a new contraceptive method; instead, most (52 percent) rely on messages from the media.
These surprising results point to the failure of parents, sex educators, and medical professionals to deliver medically accurate sex education to our nation’s youth. For many young people, school programs are their only formal education on the subject, so it is extremely important that teachers present clear, unbiased, comprehensive information to counteract the myths about fertility and contraception that kids may hear from their friends and the media. This is not possible, however, for teachers in school districts where school boards have either rejected sex education programs altogether or chosen to provide abstinence-only education.
Planned Pregnancy to Slow Growth
Eliminating unintended pregnancy around the world (including in developed countries) would reduce the number of unplanned births by 33 million a year. This would be a huge boon to population stabilization efforts, given that the earth’s population grows by about 80 million people a year. Projections show that population growth in developing countries could be reduced by 300 million to 1.26 billion people by 2050 if unmet need for family planning were fulfilled, when compared to the medium and high UN population projections, respectively. The difference in growth in the United States would be 67-120 million.
In addition to addressing unmet need, desired fertility must decline in Africa in order for the population to stabilize. By fulfilling unmet need in that region, population would still be on an upward path at mid-century. Family planning programs need to be ramped up to meet existing demand while also generating new demand—in order for that to occur, donor investments must increase markedly. A shift to lower fertility by early acceptors of family planning would help to normalize the idea of smaller families in a community, changing attitudes in people who may not initially want to use contraception or who don’t even fully comprehend that childbearing is an option. In other words, when women begin using contraception, it creates demand for contraceptive services by other women who previously were not interested in using a method. With the right improvements in reproductive health care and family planning services, there’s no reason to believe that a quick fertility transition is not possible everywhere.