Trends in sexual activity and demand for and use of modern contraceptive methods in 74 countries: a retrospective analysis of nationally representative surveys

Abstract

Background: A quarter of a century ago, two global events-the International Conference on Population and Development in Cairo, and the Fourth World Conference on Women in Beijing-placed gender equality and reproductive health and rights at the centre of the development agenda. Progress towards these goals has been slower than hoped. We used survey data and national-level indicators of social determinants from 74 countries to examine change in satisfaction of contraceptive need from a contextual perspective.

Methods: We searched for individual-level data from repeated nationally representative surveys that included information on sexual and reproductive health, and created a single dataset by harmonising data from each survey to a standard data specification. We described the relative timings of sexual initiation, first union (cohabitation or marriage), and first birth and used logistic regression to show the change in prevalence of sexual activity, demand for contraception, and modern contraceptive use. We used linear regression to examine country-level associations between the gender development index and the expected length of time in education for women and the three outcomes: sexual activity, demand for contraception, and modern contraceptive use. We used principal component analysis to describe countries using a combination of social-structural and behavioural indicators and assessed how well the components explained country-level variation in the proportion of women using contraception with fractional logistic regression.

Findings: In 34 of the 74 countries examined, proportions of all women who were sexually active, not wanting to conceive, and not using a modern contraceptive method decreased over time. Proportions of women who had been sexually active in the past year changed over time in 43 countries, with increases in 30 countries; demand for contraception increased in 42 countries, and use of a modern method of contraception increased in 37 countries. Increases over time in met need for contraception were correlated with increases in gender equality and with women's time in education. Regression analysis on the principal components showed that country-level variation in met contraceptive need was largely explained by a single component that combined behavioural and social-contextual variables.

Interpretation: Progress towards satisfying demand for contraception should take account of the changing context in which it is practised. To remove the remaining barriers, policy responses-and therefore research priorities-could require a stronger focus on social-structural determinants and broader aspects of sexual health.

Funding: UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Figure 1

Length of the interval between the median ages at first sexual intercourse and first union, and the median age at first birth for women born between 1960 and 1999 by country and region The interval between median ages at first sexual intercourse and first union (cohabitation or marriage) are shown as bars, whereas median age at first birth is shown as points. For each country, younger cohorts are presented first (blue and purple), followed by older cohorts (light and dark green). *Median age at first sexual intercourse is shown for countries without information on age at first union.

Figure 2

Proportion of sexually active women according to desire to conceive, pregnancy status, and use of a modern contraceptive method Countries are grouped according to the change over time in the proportion of sexually active women aged 15–49 years who do not want to conceive and are not using a modern contraceptive method and whether this proportion has A) decreased, B) increased, or C) remained the same. *Surveys of ever-married women only. †Surveys of ever-married women followed by surveys of all women; for India, only the all-women surveys are shown.

Figure 3

Crude odds ratios, by country, for change over time in met need for modern contraceptive methods Met need for modern contraceptive methods was estimated as the proportion of sexually active women aged 15–49 years who do not want to conceive and are using modern contraceptive methods. Where terms for interaction between age and year of survey made an important contribution to the model, we present stratified odds ratios.

Figure 4

Crude odds ratios, by country, for change over time in the prevalence of sexually active women, as a proportion of all women aged 15–49 years Women were defined as sexually active if they had had sex in the past year. Where terms for interaction between age and year of survey made an important contribution to the model, we present stratified odds ratios.

Figure 5

Crude odds ratios, by country, for change over time in the demand for modern contraceptive methods Demand for modern contraceptive methods was estimated as the proportion of sexually active women aged 15–49 years who do not want to conceive. Where terms for interaction between age and year of survey made an important contribution to the model, we present stratified odds ratios.

Figure 6

Linear relationship of PC2 score with met need for modern contraceptive methods Met need for modern contraceptive methods was estimated as the proportion of sexually active women aged 15–49 years who do not want to conceive and are using modern contraceptive methods, with the regression line from a linear regression of PC2 score and met need shown in red. The coefficients on PC2 for all included variables are shown in the table. PC2=principal component 2. *Excluding Northern Ireland.