Now, in many programs, improving access and the quality of services at the same time could increase contraceptive use further (195). Such factors as the number of contraceptive methods available, the quality of counseling about side effects, and the attitudes of providers toward their clients are key elements of access and quality (17, 30, 195). In fact, access to a choice of methods is the first of six elements of good-quality family planning services proposed by Judith Bruce (30).

In many countries, offering more methods to more couples would probably reduce unmet need, particularly when combined with improvements in service quality (179). Currently, the choices are often limited. A 1989 study based on reports from 98 countries found virtually no access to oral contraceptives in 19 countries, to the intrauterine device (IUD) in 30, to voluntary female sterilization in 37, or to vasectomy in 61. Excluding China, fewer than one-half of all people in the developing world have access to more than one or two modern contraceptive methods (122, 177).

Even where services are widely available, some women still do not have adequate access to them (2, 43). In Tunisia, for example, although services are widespread, hard-to-reach groups still need better access to services (43)—especially women with less education and rural women, among whom levels of unmet need are highest (6).

For many other people, services are available, but poor quality stands in the way of their use. For example, in Egypt 42% of contraceptive users surveyed in the 1992 DHS were using family planning services located outside their communities (25). The main reason that they gave for not going to the nearest family planning center was lack of good services there. Many went instead to more distant service centers that offered better services and wider choice of methods (187).
Some people do not use available family planning services because of unnecessary or inappropriate requirements for examinations and tests, eligibility exclusions, and provider biases that constrain the client's choice of methods (194). Programs can help solve these problems by updating medical guidelines and simplifying clinic procedures, by making more use of paramedic and nonmedical staff, and by providing more distribution modes and outlets.

Adding new methods. Offering a choice of several contraceptive methods, not just one or two, helps avoid unmet need in two ways: first, by increasing the likelihood that current users can find a new method, rather than discontinuing use entirely, when their needs change or when they experience unacceptable side effects (66), and, second, by attracting new contraceptive users (71, 151). About 1 woman in every 3 who starts using a hormonal method and about 1 in every 10 who starts using an IUD will discontinue use within one year for reasons other than desiring pregnancy. These women will need another method immediately to avoid an unintended pregnancy (4).

Research in Hong Kong, India, South Korea, Taiwan, and Thailand during the 1960s and 1970s found that contraceptive prevalence increased with each additional contraceptive method that became available (71). Also, in the Matlab, Bangladesh, family planning research project, contraceptive use rose rapidly when additional methods were introduced (150, 151). For example, in 1977 introducing injectable contraceptives helped raise contraceptive prevalence from 7% to 20%; in 1978 introducing voluntary female sterilization increased prevalence by another 10 percentage points (151).

When home delivery of injectables started, overall contraceptive use also rose rapidly in another district, Sirajganj, where contraceptive use had lagged behind the rest of Bangladesh. In eight other districts starting home delivery of injectables led to a doubling of their use in the first year. Much, but not all, of the increase came from women switching to injectables from other, less desired methods (83).

Offering injectables through home visits by field workers has been cited as the main reason that contraceptive use and continuation were higher in the Matlab project than in the Bangladesh national program, which offered injectables only on a limited basis (3). Many women everywhere value injectables because they are highly effective, long-acting, reversible, and convenient, and they can be used privately (110, 120). Today, as political and scientific uncertainties that once held back use of injectables in many countries have been resolved, the growing availability of injectables offers new opportunities to address unmet need around the world. (See Population Reports, New Era for Injectables, Series K, Number 5, August 1995.)