Aparna Jain, PhD, MPH Laura Reichenbach, PhD Unmet Need: Is it the right indicator for FP programming with Youth in Ouagadougou partnership countries? Aparna Jain, PhD, MPH Laura Reichenbach, PhD ICFP 2015 January 2016

Background

Research questions Are the current measurement approaches of contraceptive need (no need, unmet need, and met need) the most appropriate indicators for family planning programming among youth aged 15 to 24? How does age and marital status influence contraceptive need among youth in Ouagadougou partnership countries?

Methods

Data Demographic and Health Surveys Benin 2011-2012 Burkina Faso 2010 Cote D’Ivoire 2011-2012 Guinea 2012 Mali 2012-2013 Niger 2012 Senegal 2010-2011 Countries in Ouagadougou partnership were selected if they had a DHS survey conducted after 2010.

Sample size Youth 15-24 years old Benin:5,800 Burkina Faso: 6,623 Cote D’Ivoire: 3,976 Guinea: 3,661 Mali: 3,736 Niger: 3,822 Senegal: 6,648

Methods Outcome variable: Contraceptive need Unmet need Met need No need Explanatory variables: Marital status Never married Currently married/in union Formerly married Respondent age (15-19, 20-24) Covariates: education, wealth, parity, residence Unmet need to space or to limit Met need are those who are using contraception, No need included respondents who have never had sex, are not married and have not had sex in the last 30 days, infecund/menopausal, and respondents classified as having no need. With youth this is predominantly those who have never had sex.

Methods Bivariate analysis: Multivariate logistic regression: Assess effect of marital status & age on contraceptive need Multivariate logistic regression: Model I: no need (1) compared to some need (unmet need + met need, 0) Model II: unmet need (1) compared to met need (0); respondents with no need excluded We excluded the no need category from the second model as they are often included in most unmet need analyses – For youth who are not sexually active and therefore do not have a need for contraception, their inclusion in analyses can lead to an underestimate of unmet need.

Results

Need for Contraception by Marital Status   NO NEED UNMET NEED MET NEED Benin Unmarried 72.2 10.9 16.9 Married 56.8 33.9 9.3 Burkina Faso 84.4 4.7 10.8 63.3 23.4 13.3 Cote D’Ivoire 62.6 16.2 21.2 53.8 31.0 15.3 Guinea 76.2 10.3 13.5 70.4 25.5 4.1 Mali 84.6 8.6 6.8 66.8 24.1 9.1 Niger 98.3 0.93 0.74 71.9 16.3 11.8 Senegal 95.8 2.8 1.4 61.3 30.6 8.1 + Greater proportions of unmarried youth have no need for contraception. + Married women have a greater unmet need for contraception + Met need is greater for unmarried women in Benin, Cote D’Ivoire, Guinea

Need for Contraception by Age   NO NEED UNMET NEED MET NEED Benin 15-19 73.3 12.3 14.4 20-24 59.0 27.2 13.8 Burkina Faso 83.8 9.9 6.3 61.2 20.6 18.2 Cote D’Ivoire 68.1 16.4 15.2 49.6 23.3 Guinea 79.8 14.7 5.5 64.8 21.6 13.6 Mali 79.7 14.5 5.8 66.4 22.7 10.9 Niger 87.2 8.4 4.4 69.5 16.8 13.7 Senegal 88.7 9.1 2.2 20.2 6.5 Younger youth (15-19) have no need compared to older youth (20-24)

Model I: No Need for Contraception MARRIED (ref: unmarried) 15 – 19 YEAR OLDS (ref: 20 – 24 year olds) OR 95% CI Benin 1.07 (0.84-1.37) 1.35 (1.17-1.56) Burkina Faso 0.65 (0.48-0.89) 1.28 (1.06-1.54) Cote D’Ivoire 1.01 (0.80-1.26) 1.73 (1.39-2.15) Guinea 1.66 (1.27-2.19) 1.41 (1.13-1.77) Mali 0.52 (0.33-0.83) 1.03 (0.83-1.27) Niger 0.09 (0.04-0.20) 1.05 (0.82-1.35) Senegal 0.16 (0.10-0.24) 0.76 (0.61-0.95) Outcome: No need compared to some need (unmet need + met need) In four countries, 15-19 are significantly more likely to have no need for contraception compared to 20-24 years Model adjusted for education, wealth, parity, residence

Model IIa: Unmet Need for Contraception (excludes those with no need) MARRIED (ref: unmarried) 15 – 19 YEAR OLDS (ref: 20 – 24 year olds) OR 95% CI Benin 2.27 (1.57-3.27) 0.87 (0.67-1.13) Burkina Faso 1.76 (1.09-2.87) 2.66 (1.94-3.66) Cote D’Ivoire 2.10 (1.43-3.08) 1.15 (0.80-1.66) Guinea 6.92 (4.22-11.34) 2.64 (1.78-3.92) Mali 1.26 (0.82-1.96) Niger 2.37 (0.42-13.4) 1.25 (0.80-1.94) Senegal 1.77 (1.07-2.92) 1.13 (0.66-1.92) Unmet need relative to met need (excluding those with no need) 15-24 year old Married adolescents are more likely to have an unmet need than unmarried adolescents – and significant in 6 out of 7 countries Model adjusted for education, wealth, parity, residence

Model IIb: Met Need for Contraception (excludes those with no need) UNMARRIED (ref: unmarried) OR 95% CI Benin 2.08 (1.44-3.01) Burkina Faso 1.66 (1.03-2.67) Cote D’Ivoire 1.76 (1.21-2.57) Guinea 5.28 (3.30-8.45) Mali 1.73 (0.96-3.10) Niger 2.02 (0.34-11.97) Senegal (1.01-2.72) In this slide we demonstrated this by reversing the coding for the outcome variable and for marital status (Met need versus unmet need – excludes no need) (reference group is no married) Model adjusted for education, wealth, parity, residence

Discussion

Discussion NO NEED UNMET NEED MET NEED 15 - 19 0.68 0.16 20 - 24 0.50 0.27 0.23 25 - 29 0.51 0.26 30 - 34 0.57 0.22 0.21 35 - 39 0.56 40 - 44 0.19 45 - 50 0.80 0.11 0.09 Table shows contraceptive by age for all women in Burkina Faso. There are very few differences in contraceptive need by age. The reason why older women in the no need category is very different than younger women: + as respondents grow older, more women transition to menopause or infecundablility (no need) and few older women return to the unmet need category. + The majority of youth in the no need category are NOT sexually active; this changes over time as they transition into sexual activity and marriage. Cote D’Ivoire DHS 2011-2012

Discussion As youth transition into different life stages, their need and use of contraception changes 6 of 7 countries 15-19 year olds have no need for contraception compared to 20-24 years old (significant in 4 countries) 7 countries unmarried youth who are sexually active are more likely to use contraception than married women (significant in 5 countries) 7 countries sexually active married youth were most likely to have an unmet need (significant in 6 countries) + 15-19 year olds are not having sex therefore they do not need contraception + As they transition to sexually active but remain unmarried, there need for contraception is met (primarily through condoms) + As they marry though, they have an unmet need suggesting that marriage is no guarantee that youth will begin to use contraception as they may encounter social barriers related to husband’s attitudes and cultural expectations of fertility.

Discussion Family planning programming for youth needs to consider: Age Sexual initiation Marital status One size does not fit all!