A Complementary Metric to Unmet Need for Family Planning in Sub-Saharan Africa: Quantifying the High-Risk Fertility Contraceptive Gap

Abstract Background Sub-Saharan Africa (SSA) faces a high maternal and child health burden, partly due to low contraceptive use and high fertility rates, with many women having unmet family planning needs. Current measures of unmet need for family planning, based on stated fertility intentions, may overlook women with high-risk fertility due to subjective biases, underestimating contraceptive needs. This study introduces the High-Risk Fertility Contraceptive Gap (HRFCG), a complementary risk-based metric of contraceptive gap. This study assesses HRFCG prevalence, its relationship to current unmet-need measures, and its potential for integration into standard unmet need assessments. Methods This is a secondary analysis of pooled Demographic and Health Survey (DHS) data from 28 sub-Saharan African countries, covering 266,923 married women aged 15–49. High-Risk Fertility (HRF) characteristics were defined as attempting pregnancy or giving birth before age 18, after age 35, after four or more children, or within 24 months of a prior birth. The HRFCG refers to non-use of contraception among women with HRF characteristics. Result Three-quarter of women had at least one high-risk fertility characteristic. Among those with high-risk characteristics, 37% expressed no desire to space or limit births. HRFCG prevalence was 28.5%, exceeding conventional unmet need for family planning (20.9%). On average, 15.3% of women had HRFCG but did not meet conventional unmet need criteria. Integrating HRFCG with the unmet need metric increased the overall estimate from 20.9% to 36.2%, capturing women needing contraception due to fertility desires or high-risk characteristics. Conclusions The HRFCG provides a vital risk-based metric to identify women needing family planning, complementing fertility intention-based unmet need measures for a more comprehensive assessment. Its integration with conventional unmet need indicators is practical, leveraging routinely collected DHS and other similar survey data. This approach enhances equity-focused monitoring and guides targeted strategies to address unmet needs effectively.