“Do you want to get pregnant in the next two years?”How would you answer this question? How would you answer it if one of your neighbors—or relatives—were standing at your front door, in your living room, or even in a health clinic, asking it?For many women (or men) around the world—both unmarried and married—the answer is no.

And, as I learned a few months ago, if you’re a young unmarried woman in rural Tanzania, and dare to visit a health center to ask for contraception, the response to your request for contraception is often followed by more questions from the health worker: “Are you having sex? Why are you having sex?” A few young Tanzanian women shared with me that they and their friends, those few who tried to get services, end up leaving empty-handed and embarrassed, not daring to even answer the questions about whether and why they’re sexually active.

If you’re a married woman participating in a door-to-door Demographic and Health Survey, a standardized door-to-door in-person survey that has been conducted in countries around the world for the past 32 years, the question about wanting to get pregnant is followed by another question, “Are you using any form of contraception?”If you answer “no” again, you are categorized as having an “unmet need” for contraception. It’s a term commonly used by family planning experts, demographers, and other global health and development specialists. Individuals, communities, and even countries are classified according to their level of unmet need, and those with higher unmet need are considered lacking in meeting the basic needs of their populations.  An estimated 225 million women in the world have an unmet need for contraception.

But what if your answer to the first question about wanting to get pregnant is not ‘yes’ or ‘no,’ but rather, ‘it depends.’ It depends on a lot of things, including how your family is doing financially—and whether the rains come to make the crops grow—how your personal relationship is going with your partner, how your own career might be advancing. In some communities, it might even include how many children one of your co-wives has given birth to, or pressure from your husband, your mother, or even your mother-in-law to get pregnant, to demonstrate your fertility. Or what if you’re just not sure? What if it’s “no” today, and “maybe” tomorrow?

Only 5% of women say that they are not using contraceptives because they do not have access to contraceptives.

Unmet Need for Contraception in Developing Countries: Examining Women’s Reasons for Not Using a Method, a study recently published by the Guttmacher Institute, examines why “sexually active women in developing countries who have an unmet need for contraception, meaning they wish to avoid pregnancy but are not currently using any contraceptive (traditional or modern).” Researchers, led by Gilda Sendgh, found that a full 10% of women aged 15–49 in developing regions do not want to get pregnant and are not using “any contraceptive method.”

Major reasons for not using contraception mentioned by married women include concerns about side effects and health risks (26%), a belief (and likely misconception) they weren’t having sex often enough to need contraception (24%), and that they’re breastfeeding and/or have not had their period since their last birth and don’t think they can get pregnant (20%).  In general, women who are sexually active but not married cite similar reasons.

What’s not on the top of this list? Only 5% of women say that they are not using contraceptives because they do not have access to contraceptives. In other words, women who may, indeed, be able to access both a contraceptive and, if needed, a health worker to administer it, still are considered to have an unmet need.

What’s also not on this list? Contraceptive choices made by men, or their partners. Men are rarely asked in routine surveys if they want their partner(s) to become pregnant in the next two years and what, if any, contraceptive decisions they have made.   Sendgh and her research team used data from Demographic and Health Surveys conducted in 52 countries (32 in Africa, 13 in Asia and seven in Latin America and the Caribbean) between 2005 and 2014 to analyze why married women are not using contraception. In 31 of these countries, they also examined the issue among unmarried women. Concerns about side effects and health risks—which have, according to the researchers, grown over time in a wide variety of countries and cultures, may be a sign that the contraceptive methods themselves, or at least women’s perceptions of them, are problematic.

Among sexually active never-married women with unmet need, infrequent sex is the most common reason given for nonuse (41%), followed by “not married” (29%). Researchers found that “about half of the women citing infrequent sex as their reason for nonuse were sexually active within the past three months, which suggests that many women in this group may be underestimating their risk of becoming pregnant.“ Citing “not married” as a reason for not using family planning services might be a reflection of societal norms, as in rural Tanzania, or, as some young people have mentioned to me in various countries, fear that “the nurse will tell your mother or aunt.”

The authors suggest a range of possible responses to address each reason for nonuse. These include improving counseling that addresses specific concerns—real and imagined—about side effects and health risks; ensuring women are informed about their fertility and pregnancy risk; and helping women choose contraceptive methods that are most appropriate for the types of relationships they have. It is important to continue focusing on the roles of social norms and health workers in influencing use or nonuse.

Social norms rule

Cultural norms—such as the taboo of even talking about sex, especially among unmarried people—are deeply rooted and complex. We need to continue to invest in better understanding how and why people make decisions about getting pregnant and giving birth. Limiting our understanding to answers to three questions in a Demographic and Health Survey—Want to get pregnant? Using contraception? Why not?—may in fact limit our approaches to ensuring that voluntary family planning is truly available to those who want contraception. The answer might not always be a quick ‘yes’ or ‘no,’ but rather, ‘I don’t really know right now.’ The questions—and answers—are nuanced. In addition, access to contraception for unmarried individuals—no matter how old they are, but especially if they’re considered “too young to be having sex” in their society—remains challenging throughout the world.

As reported in Devex (Out with ‘family’ planning, in with ‘future’ planning), on IntraHealth’s VITAL (Future Planning: Young People Making Choices), and in The Lancet Global Health (Family planning versus contraception: What’s in a name?), part of the challenge may be semantics; adolescents and unmarried people in general might not think that the words ‘family planning’ apply to them.

Health workers count

Most people in the world still need the advice and expertise of a health worker as they’re making reproductive and contraceptive decisions, especially when opting for long-acting reversible contraceptives and permanent methods. The world needs more health workers—millions more, including health workers trained in both contraceptive technology and high-quality, context-appropriate contraceptive counseling.

As my IntraHealth International colleague Boniface Sebikali wrote a few years ago, health workers do influence attitudes and decisions about family planning. Health workers often bring their own biases to work, restricting married women from accessing contraceptives without spousal approval, and restricting unmarried people, especially young women, from accessing any contraception. Health workers also sometimes promote the misconception that women shouldn’t use long-acting or permanent methods until they’ve had a certain number of children, and often don’t provide accurate information about potential side effects. Health workers sometimes even recommend contraceptive methods that are easier and faster for them to provide, rather than exploring with clients the best method for them. And, at least according to the results of the Guttmacher study, health workers might not be providing accurate information about frequency of sex and the need for contraception.

We need to better understand how and why health workers provide the counseling and services they do, and what preconceptions and social norms are affecting their own decision making, to better train and support them—and ensure that they are facilitators, not barriers, in helping both women and men make informed choices and, ultimately, meet unmet need.