When women have control over their reproductive health, it can transform their entire lives. But for too long, and in too many ways, the international development community has not paid enough attention to what women actually want and need, including when it comes to family planning efforts.
This is starting to change. The Bill & Melinda Gates Foundation is joining the broader movement toward asking women about their desires, preferences, and intentions when it comes to contraceptive use. One example is measuring women’s intent to use a modern contraceptive method by asking them directly whether and when they want to use a family planning method and what methods they prefer.
Historically, family planning surveys have asked women whether they want children in the future and if they are already using modern contraception. On that basis, they have been classified as either having or not having an “unmet need.” This calculation is used to measure progress towards meeting this need. This indirect assessment can misclassify some women who may want contraception or assign unmet need to women who have no intention of using it or who do not want children in the near future.
More surveys are now asking women whether they intend to use contraception and if so, when. Early research shows that focusing on “intent to use” is far more predictive of whether a woman will subsequently use contraception than looking at unmet need. Depending on how the survey is structured, respondents may have the option to describe why they are not using a contraceptive method if they want to, or they may be presented with a list of common reasons, such as lack of support from their spouse or concern about side effects, to choose from. This direct elicitation gets researchers a step closer to understanding what women truly want and allows family planning programs to be tailored accordingly.
This is an exciting shift. Making and measuring progress in meeting genuine demand at the population level requires more accurate estimates of how many women affirmatively intend to use contraception. Data show that women assigned unmet need frequently state no intent to use contraception, and vice-versa, and women with no 'unmet need' often do state an intent to use. In a nine-country analysis, researchers at the Institute for Disease Modeling, part of the Bill & Melinda Gates Foundation’s Global Health Division, found that 15% of women who were not using contraception were considered to have unmet need despite having no intent to use it, while 9% of women who were considered to not have unmet need actually had the intent to use it. A more woman-centered approach provides valuable insights and information that family planning programs can use to better serve women and thereby have greater impact.
The goal with this new shift is ultimately to adjust our programs according to women’s own expressed intentions, and thereby have a greater impact reaching those who themselves seek contraception. The following two stories illustrate why intent matters in ensuring that as many women as possible can make informed choices about their reproductive lives.
Susan Ontiri, a family planning researcher, knows this from her work, and from her own life. Lilian, a mother who has used contraception in her family planning journey, reminds us that behind each data point is a real woman taking ownership over her health and her family’s future.
The Kenyan family planning researcher
Susan Ontiri was a student at Kenya’s Moi University School of Public Health when she ran into a friend from high school at the student dormitories. The classmate had been one of the brightest students in their graduating class, so Ontiri was surprised to see that, instead of pursuing a degree, she was working as a security guard. She told Ontiri that an unplanned pregnancy had derailed her studies.
Ontiri had always been interested in public health, but she knew at that moment that she wanted to work in family planning, to give women like her friend the means to control their futures.
Now the country director at the International Centre for Reproductive Health (ICRH) Kenya, Ontiri has conducted research on family planning for nearly 15 years. She loves her work. “It helps me understand people’s behaviors, choices, practices,” she says. “You talk to all women, and they have their own story about using family planning…. It’s quite personal.”
Researchers classify someone as having unmet need if they are not using a contraceptive method and have stated they do not wish to get pregnant. But Ontiri knows from her own experience that assumptions about women’s motivations are not always accurate. “There are times in my reproductive health journey when I have not been using a contraceptive method, by choice,” she says. “Yet looking at that definition, you’re considered to have unmet needs.”
She adds: “We end up lumping together women who truly desire contraceptives but for whichever reason did not have access to it—either because of accessibility, or availability, or maybe even because of male interference—with women who have intentionally decided not to use a contraceptive method.”
Asking women about their intent to use contraception, in her view, gives them agency and allows them to explain their plans and share what is holding them back. “Given that this is reproductive health, choices are the center,” she says. Family planning research “should be a place where we are asking, ‘Is it by their choice?’”
Indeed, the follow-up questions—such as “What is stopping you from using contraception if you do intend to use a method?” or “Why do you not intend to use contraceptives?”—can yield valuable insights that can inform efforts to improve contraceptive access. Perhaps a woman needs a covert method that she can hide from her spouse, perhaps she fears community disapproval, or she wants to avoid side effects. Or maybe she’s in between methods or has never used contraception before. Each circumstance requires a different kind of intervention, but first it requires listening to women.
“An indicator that includes the autonomy or the choice of a woman, in terms of their reproductive health, should actually give us a clearer picture,” Ontiri says. She knows many family planning researchers who are excited to measure intent to use, but a standard definition is lacking. For example, ICRH Kenya conducted a survey — the Performance Monitoring for Action or PMA survey —that asked women if they intended to use contraceptives at any time in the future, and those who responded affirmatively were asked when they would start using them. But other surveys have used different definitions.
Finding a common definition and way to measure intent to use has become a topic of lively conversation at global conferences and convenings, Ontiri says.
She is optimistic that it will one day be defined and measured, so that she and her colleagues can use it to make sure their programs are reaching women facing barriers to contraception. After all, Susan notes, family planning practitioners have been asking women this question for years without collecting the data in a standardized or formalized way.
“I think the time is ripe to revisit this and have robust discussions on how this can be done,” Ontiri says. “Whenever you talk about intent, everybody is like, ‘We actually need to have this indicator.’”
The Ugandan mother and farmer
Since she was a young girl, Lilian wanted a family. (At her request, her name has been changed to protect her privacy.)
She always thought 25 was the best age to become a mother. At that age, she says, you’ve likely finished school and have some independence. “You are mature, you can feed a baby, you can decide for yourself.” Lilian earned a diploma in medical records management and now breeds animals on her parents’ farm in Kampala, Uganda’s capital.
Lilian met her husband, a lay reader at a church, when she was 23 and he was 25. He was ready to start a family right away, but Lilian wanted to wait a little bit longer. She had learned about family planning in secondary school and knew that it was a good option for spacing births. But she didn’t know many details. Friends told her that contraception could interfere with menstruation, cause rapid weight gain or loss, and make it more difficult to eventually get pregnant. She intended to use contraception but needed additional information to make the right choice.
While picking up medication at a local government hospital, Lilian found out about a workshop on family planning and decided to attend. There she learned about pills she could take every day and discontinue at any time, an injection that lasted three months, and an injection that lasted three years.
Better contraceptives are coming
After discussing the options, she and her husband chose the three-month injection. They returned to the hospital together so he could learn more and watch her get the shot. She still had some concerns about potential side effects, however. “I personally feared it because I didn’t know whether I would have my periods during those three months,” she says. She felt a bit unwell the day of the injection, but her body quickly normalized. She also felt a sense of relief. “I felt good, because I knew I won’t conceive when I don’t want to,” she says.
Lilian liked the three-month duration of her chosen method, which gave her time to reflect on whether she was ready to start a family and revisit her intentions on continuing to use contraception or not. “You’ve got time to plan,” Lilian says. “Within the next two or three months, I can decide whether to go for another one or opt to get pregnant.” She had one more injection after that “because I wasn’t ready for pregnancy,” she says.
Lilian went on to have her first child just as she had planned—at age 25. She had many friends who were in relationships but didn’t want to get pregnant. After listening to their stories, she encouraged them to learn about their family planning options. They were concerned about possible side effects, as she had been, but she assured them that she felt fine a day after the shot and her periods had remained normal.
Lilian’s wishes and intentions for planning her family evolved over time, highlighting the importance of listening to women’s expressed desires regarding contraceptive use. The concept of unmet need would not have fully captured the nuances of her life—it assumes that a married woman like Lilian who wants to be pregnant within two years does not have an unmet need for contraception. Lilian in fact intended to use it for a short time, just until she was ready to try for a pregnancy. By contrast, asking Lilian about her intent to use contraception would better capture her immediate need, helping ensure she could access the method of her choice.
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