Background
Unmet need for family planning (FP) is used to measure gaps in FP access and use, and for women living with HIV (WLWH), risk of vertical HIV transmission. Criterion to assess need for FP are used in FP/HIV integrated services to direct FP service delivery, yet applying the World Health Organization (WHO) definition of need for FP may underestimate the proportion of WLWH whose FP needs are not met.
Methods
We used baseline data from WLWH receiving HIV care and enrolled in an ongoing cluster randomized clinical trial evaluating a digital reproductive health intervention (vs. standard of care) in Kenya. Women were enrolled at 10 facilities and completed surveys assessing demographics, reproductive history, fertility and FP use. Need for FP was defined as having no desire for pregnancy for ≥2 years, being sexually active and married/partnered. Unmet need for FP by the WHO definition was calculated as the number of women not using a modern FP method and with a need for FP divided by the number with a need for FP. We compared the WHO definition of unmet need with definitions that used alternate criteria for preferences for birth spacing/limiting, current partners, and sexual activity, and made statistical comparisons using χ2 tests.
Results
Among 3296 WLWH enrolled, median was age 33 years (interquartile range 28-38), 72% had regular partners, 74% were sexually active, and 41% had a desire for future pregnancy. Only 9% of WLWH were planning a pregnancy in ≤2 years. Among WLWH who were not currently sexually active and did not have a regular partner, 36% reported last sex was ≤2 months ago. Overall, 7.8% of WLWH were classified as having unmet need using the WHO definition. Unmet need was 4.0% higher (RR 1.51, 95% CI 1.21-1.88, p<0.001) by including women who did not want to become pregnant now and 3.3% higher (RR 1.42, 95% CI 1.37-1.77, p=0.002) by removing current sexual activity criteria, and 1.2% higher (RR 1.15, 95% CI 0.92-1.45, p=0. 2) by including women without regular partners who were sexually active (Figure). Reducing the desired time to pregnancy to ≤1 year only captured an additional 0.3% of women who would be classified as having unmet need (p>.05).
Conclusions
The WHO definition of unmet need may misclassify 1-4% of WLWH as not having a need for FP, which translates to a 15-50% increase in estimates of unmet need for FP and suggests there are missed opportunities to provide FP counseling and services to WLWH who do not present as having a need for FP.