Assessing disparities in major family planning indicators by marital status
Background: The indicators of modern contraceptive use and demand for family planning satisfied with modern methods are used to measure access to sexual and reproductive health services, but international estimates of these indicators are often restricted to married/in-union women, or else only highlight the value among all women in aggregate. This paper presents international estimates of these indicators disaggregated by marital status, allowing for the identification of disparities and deficits between groups that likely face distinct obstacles and stigmas related to sexual and reproductive healthcare. This paper also presents a sensitivity analysis aimed at assessing the potential for bias across marital status exhibited by the standard operationalized definition of having a need for family planning. Methods: Data on contraceptive use and need for family planning were extracted separately by marital status from 872 surveys conducted in 160 countries and territories since 1970. Variations in survey questions and definitions of modern versus traditional methods were adjusted via crosswalking as necessary. Indicators were modeled by-age using a Spatiotemporal Gaussian Process Regression to generate comprehensive time series estimates for 204 countries and territories from 1970 to 2019. Sensitivity analyses leveraged available microdata to perform counterfactual re-extractions of surveys to determine the proportion of contraceptive users who satisfy the current criteria for having a need for family planning. Results: Age-standardized global modern contraceptive prevalence in 2019 was 53.9% (53.0-54.8%) for married/in-union women and 24.1% (23.3-24.9%) for unmarried women. Modern contraceptive prevalence for ages 15-49 in 2019 ranged from 0.2% (0.1-0.4%) among unmarried women in Afghanistan to 92.2% (90.1-93.8%) among married/in-union women in China. Age-standardized global demand for family planning satisfied with modern methods in 2019 was 72.3% (71.5-73.1%) for married/in-union women and 81.6% (80.8-82.5%) for unmarried women. Demand satisfied in ages 15-49 in 2019 ranged from 4.3% (3.3-5.6%) among married/in-union women in Somalia to 97.6% (96.6-98.3%) among unmarried women in Bangladesh. Sensitivity analyses found large differences by marital status in the age-standardized proportion of reversible contraceptive users otherwise meeting the definition of having a need for family planning, with global 2019 values of 84.0% (82.9-84.8%) for married/in-union women and only 15.4% (13.0-17.8%) for unmarried women. Interpretation: Significant disparities exist in family planning indicators across both geography and marital status. Interestingly, while unmarried women exhibit lower by-age rates of modern contraceptive use, in most regions they also experience higher levels of demand for family planning satisfied with modern methods. However, lower proportions of unmarried reversible contraceptive users found to otherwise meet the criteria of having a need for family planning suggest that the need for family planning indicator may have differential sensitivity across marital status, resulting in underestimates of unmet need among unmarried women. In addition to expanding investments in sexual and reproductive health services in developing contexts, the results of this study suggest that additional research into potential adjustments to standard family planning indicators is warranted in order to increase ascertainment of unmet need among unmarried women.
Contraception, Family Planning, Sexual and Reproductive Health, Public health
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