A Case of ‘Unmet need’? Barriers to Women’s use of Modern Contraceptives in the Republic of Yemen

Abstract

A CASE OF ‘UNMET NEED’? BARRIERS TO WOMEN’S USE OF MODERN CONTRACEPTIVES IN THE REPUBLIC OF YEMEN BY CHRISTINA HELLMICH* The existence of barriers to fertility regulation has frequently been considered as an important determinant for the pace of fertility decline or its delay.1 Barriers to contraception account for a substantial proportion of unwanted and mistimed births. Above all, barriers to family planning methods have enormous implications for the health and wellbeing of women. In fact, in 1994 the United Nations Programme of Action, adopted at the International Conference on Population and Development (ICPD) in Cairo, called on ‘all countries . . . to identify and remove all the major remaining barriers to the utilisation of family planning services’. Furthermore, it set the goal of ‘public, private and non-governmental family planning organisations to remove all programme-related barriers to family planning use by the year 2005’.2 Nonetheless, barriers remain. The Yemen Demographic and Health Survey (DHS) of 1997 confirmed the existence of a largely ‘unmet need’ for family planning in the country, as 23 per cent of the women surveyed expressed their desire to limit or space births but were not using any form of contraception.3 The reason for this situation was primarily found in the inadequate availability of contraception due to its inaccessibility or high cost.4 Despite the proclaimed intentions of the Yemeni government to improve the availability and quality of reproductive health services, with a prevalence rate of only 9.4 per cent the use of modern contraception in Yemen continues to rank among the lowest in the Middle East and North Africa. To gain a meaningful understanding of the reasons why the stated fertility preferences of Yemeni women and their actual contraceptive behaviours appear to be contradictory is the goal of this paper. While a review of the demographic and family planning literature reveals many references to factors that limit the practice of contraception, little has yet been said about the specific case of Yemen.5 As such, the following discussion relies heavily on primary data.6 The evaluation of * University of Reading. I would like to acknowledge the generous funding of the Leverhulme Trust in support of this research. 1 Barriers are defined as the factors that hinder realistic availability of the technologies as well as of the correct information that women need in order to control their fertility. 2 United Nations (1994). 3 Central Statistical Organisation and Macro International (1997), p. 64. For the same conclusion, see Marie Stopes International (2000). 4 On ‘unmet need’ see Robey et al. (1993); Pritchett (1994); Westoff and Bankole (1995). 5 For a comprehensive literature review, see Campbell et al. (2006). 6 Data presented in this paper were collected during 20 months of ethnographic fieldwork in Yemen. The Maghreb Review, Vol. 34, 1, 2009 The Maghreb Review 2009 This publication is printed on longlife paper j:MARELAY 14-9-2009 p:18 c:0 key findings from group discussions and in-depth interviews with Yemeni women is combined with an analysis of the statistical data from the DHS of 1997 as well as other information derived from other secondary sources. The underlying theoretical model is the Easterlin Synthesis Framework according to which fertility regulation is a function of two classes of factors, namely the strength of the motivation to avoid pregnancy and the costs, both perceived and real, of practising contraception, or, in other words, the barriers to contraceptive use.7 To enable a nuanced analysis, identified barriers have been divided into the following categories: knowledge about contraception (narrowly defined in terms of awareness of various methods and means of obtaining them); concerns about sideeffects , misinformation and fears (as a result of both the lack of accurate information about methods and the prevalence of traditional concepts of the female body, fertility and illness); perceptions of the social, cultural and religious acceptability of contraception (with a specific emphasis on husbands’ opposition and religious incompatibility); and provider bias and quality of reproductive health services. The analytical value of this breakdown is twofold. It gives structure to the analysis of complex and interrelated issues. Equally importantly, it provides an organizing framework for the assessment of the policy and programmatic...