Estimating progress towards meeting women's contraceptive needs in 185 countries: A Bayesian hierarchical modelling study

Abstract

Background: Expanding access to contraception and ensuring that need for family planning is satisfied are essential for achieving universal access to reproductive healthcare services, as called for in the 2030 Agenda for Sustainable Development. Monitoring progress towards these outcomes is well established for women of reproductive age (15-49 years) who are married or in a union (MWRA). For those who are not, limited data and variability in data sources and indicator definitions make monitoring challenging. To our knowledge, this study is the first to provide data and harmonised estimates that enable monitoring for all women of reproductive age (15-49 years) (WRA), including unmarried women (UWRA). We seek to quantify the gaps that remain in meeting family-planning needs among all WRA.

Methods and findings: In a systematic analysis, we compiled a comprehensive dataset of family-planning indicators among WRA from 1,247 nationally representative surveys. We used a Bayesian hierarchical model with country-specific time trends to estimate these indicators, with 95% uncertainty intervals (UIs), for 185 countries. We produced estimates from 1990 to 2019 and projections from 2019 to 2030 of contraceptive prevalence and unmet need for family planning among MWRA, UWRA, and all WRA, taking into account the changing proportions that were married or in a union. The model accounted for differences in the prevalence of sexual activity among UWRA across countries. Among 1.9 billion WRA in 2019, 1.11 billion (95% UI 1.07-1.16) have need for family planning; of those, 842 million (95% UI 800-893) use modern contraception, and 270 million (95% UI 246-301) have unmet need for modern methods. Globally, UWRA represented 15.7% (95% UI 13.4%-19.4%) of all modern contraceptive users and 16.0% (95% UI 12.9%-22.1%) of women with unmet need for modern methods in 2019. The proportion of the need for family planning satisfied by modern methods, Sustainable Development Goals (SDG) indicator 3.7.1, was 75.7% (95% UI 73.2%-78.0%) globally, yet less than half of the need for family planning was met in Middle and Western Africa. Projections to 2030 indicate an increase in the number of women with need for family planning to 1.19 billion (95% UI 1.13-1.26) and in the number of women using modern contraception to 918 million (95% UI 840-1,001). The main limitations of the study are as follows: (i) the uncertainty surrounding estimates for countries with little or no data is large; and (ii) although some adjustments were made, underreporting of contraceptive use and needs is likely, especially among UWRA.

Conclusions: In this study, we observed that large gaps remain in meeting family-planning needs. The projected increase in the number of women with need for family planning will create challenges to expand family-planning services fast enough to fulfil the growing need. Monitoring of family-planning indicators for all women, not just MWRA, is essential for accurately monitoring progress towards universal access to sexual and reproductive healthcare services-including family planning-by 2030 in the SDG era with its emphasis on 'leaving no one behind.'

Fig 1. Percentage of WRA who used a modern contraceptive method by marital group for the period 1990–2030, by World Bank income group and subregion.

The country classification by income level is based on June 2019 gross national income per capita from the World Bank. Estimates are indicated for the years 1990, 2000, 2010, and 2019 by solid circles and interpolated by solid lines. Projections for the year 2030 are indicated by open circles and interpolated by dashed lines. Shaded ribbons indicate 95% UIs; intervals for projection years are shaded lighter. UI, uncertainty interval; WRA, women of reproductive age (15–49 years).

Fig 2. Proportion of need for family planning satisfied by modern methods among WRA by marital group for the period 1990–2030, by World Bank income group and subregion.

The country classification by income level is based on June 2019 gross national income per capita from the World Bank. Estimates are indicated for the years 1990, 2000, 2010, and 2019 by solid circles and interpolated by solid lines. Projections for the year 2030 are indicated by open circles and interpolated by dashed lines. Shaded ribbons indicate 95% UIs; intervals for projection years are shaded lighter. UI, uncertainty interval; WRA, women of reproductive age (15–49 years).

Fig 3. Percentage-points change between 2000 and 2019 in the proportion of WRA who used a modern contraceptive method, by marital status.

The 95% UIs are displayed by horizontal lines. UI, uncertainty interval; WRA, women of reproductive age (15–49 years).

Fig 4. 2019 estimates for family-planning indicators among UWRA.

Median estimates of (A) modern contraceptive prevalence, (B) unmet need for a modern method, and (C) the proportion of need for family planning satisfied by modern methods. For countries marked with ‘*,’ no survey-based observations are available for UWRA. The base map was obtained from Natural Earth (https://naturalearthdata.com). The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations. UWRA, women of reproductive age (15–49 years) who are unmarried and not in a union.

Fig 5. Proportion of UWRA among WRA using modern contraception by World Bank income group and by subregion in 2000 and 2019.

The 95% UIs are displayed by horizontal lines. In the United Nations classification, the more developed regions comprise all countries of Europe, Northern America, Australia and New Zealand, and Japan. The less developed regions comprise all other countries. The country classification by income level is based on June 2019 gross national income per capita from the World Bank. UI, uncertainty interval; UWRA, women of reproductive age (15–49 years) who are unmarried and not in a union; WRA, women of reproductive age (15–49 years).

Fig 6. Number of WRA having unmet need for modern methods by subregion in 2000 and 2019.

The 95% UIs are displayed by vertical lines. UI, uncertainty interval; WRA, women of reproductive age (15–49 years).

Fig 7. Proportion of need for family planning satisfied by modern contraceptive methods among WRA, median and 95% UIs, by subregion.

Estimates are shown for the years 2000 and 2019. The 95% UIs are displayed by solid horizontal lines and median estimates by the solid circles. Projections for 2030 are shown using open circles and dashed lines. In United Nations classification, the more developed regions comprise all countries of Europe, Northern America, Australia and New Zealand, and Japan. The less developed regions comprise all other countries. The country classification by income level is based on June 2019 gross national income per capita from the World Bank. Note: results for all countries presented in S2 Appendix. UI, uncertainty interval; WRA, women of reproductive age (15–49 years).

Fig 8. Proportion of need for family planning satisfied by modern contraceptive methods among WRA, median and 95% UIs, by country, among countries where proportion of need for family planning satisfied by modern contraceptive methods was less than 50% in 2000.

The 95% UIs are displayed by solid horizontal lines and median estimates by the solid circles. Projections for 2030 are shown using open circles and dashed lines. UI, uncertainty interval; WRA, women of reproductive age (15–49 years).