Insights into Unmet Need in Ghana

Background Despite Ghana’s decline in fertility, the most pronounced in West Africa, over a third of women of reproductive age in the country reported unmet need for family planning in 2008. Any advances in our understanding of the causes of unmet need could have profound implications for programmes. Objectives This study aims to establish the relative importance of lack of access and attitudinal resistance towards use of family planning for different population and geographical strata in Ghana. It is intended to inform policy makers on the priority that should be given to behaviour change communication or improved access/information, and also helpful to interventions to reduce health concerns and fear of side effects, such as provision of broader method mix and better counselling. Methods Adapting the measures developed by Cleland et al. (2011), we identified whether women with unmet need for family planning have access to (defined by knowledge of pills and injectables, and supply sources), and attitudinal acceptance of (defined by intention to use in the future), family planning. We assessed variations of unmet need across different population strata. We also estimated risk ratios of having unmet need across the population strata relative to using modern contraceptives. The analyses were focused on 1294 fecund and non-pregnant non-postpartum abstaining women aged 15-49 who were married or cohabiting at the time of the 2008 Ghana Demographic and Health Survey. Results Forty-two percent of the women had unmet need for family planning, among whom 77% had access and 56% had attitudinal acceptance. Though current use of a modern method was higher among women who wanted no more children than among those wishing to delay the next birth, unmet need was also much higher (55% versus 36%). Non-use among limiters accounted for 45% of all unmet need. There were substantial inequalities across population strata. More than 50% of women living in the Southern belt (Western, Central and Volta regions), those with no education, or women in the poorest quintile had unmet need for family planning. Problems of access were part of the explanation for high unmet need in these groups, though lack of knowledge or access was an uncommon reason given for non-use. Sixty percent of women who had a birth in the past 2 years had unmet need, and it was even higher among breastfeeding women. The dominant self-reported reason for non-use of family planning was health concerns/fear of side effects (43%), followed by infrequent sex (17%) and respondent’s opposition (14%). One-third of all women with unmet need had previously used pills or injectables. Those stating infrequent sex as a reason for non-use were much more likely to have abstained in the past month. Recent abstinence was strongly related to the desire to avoid another birth for at least two years and to non-use of contraception. Temporary abstinence or reduced coital frequency appears to be an alternative to modern contraceptive use. Though unmet need and fertility level are lower among more privileged strata (women with secondary schooling and those living in Greater Accra), modern method use has declined in these groups and traditional methods, particularly periodic abstinence, are more commonly used