Fear, opposition, ambivalence, and omission: Results from a follow-up study on unmet need for family planning in Ghana

INTRODUCTION: Despite a relatively strong family planning program and regionally modest levels of fertility, Ghana recorded one of the highest levels of unmet need for family planning on the African continent in 2008. Unmet need for family planning is a composite measure based on apparent contradictions between women’s reproductive preferences and practices. Women who want to space or limit births but are not using contraception are considered to have an unmet need for family planning. The study sought to understand the reasons behind high levels of unmet need for family planning in Ghana. METHODS: A mixed methods follow-up study was embedded within the stratified, two-stage cluster sample of the 2014 Ghana Demographic and Health Survey (GDHS). Women in 13 survey clusters who were identified as having unmet need, along with a reference group of current family planning users, were approached to be reinterviewed within an average of three weeks from their GDHS interview. Follow-up respondents were asked a combination of closed- and open-ended questions about fertility preferences and contraceptive use. Closed-ended responses were compared against the original survey; transcripts were thematically coded and analyzed using qualitative analysis software. RESULTS: Among fecund women identified by the 2014 GDHS as having unmet need, follow-up interviews revealed substantial underreporting of method use, particularly traditional methods. Complete postpartum abstinence was sometimes the intended method of family planning but was overlooked during questions about method use. Other respondents classified as having unmet need had ambivalent fertility preferences. In several cases, respondents expressed revised fertility preferences upon follow-up that would have made them ineligible for inclusion in the unmet need category. The reference group of family planning users also expressed unstable fertility preferences. Aversion to modern method use was generally more substantial than reported in the GDHS, particularly the risk of menstrual side effects, personal or partner opposition to family planning, and religious opposition to contraception.