Update: Lant Pritchett has kindly responded to my invitation and posted his thoughts: "No need for unmet need." Check out the comments section.
A water cooler conversation (yes, geeky conversations about development are more common than VCU-Butler matchup in the Final Four around here, sigh…) I was having with a couple of colleagues last week made me wonder if the answer to the question in the title of this post is not clear. One of my colleagues, an economist, started by saying that she came into this thinking that ‘unmet need’ was a hyped-up notion with no good evidence behind it – a position she (and I) suspected is held by many economists: we think some demographers made this stuff up!
She then added that she has now come to think that there may be something to the notion that women in some developing countries would like to use contraceptives but that they simply cannot find or access them. She specifically said, if my memory serves me right, that if we were to increase the supply of birth control methods in these places, the take-up rates would go up. I cannot remember whether she then drew the conclusion that unwanted pregnancies would go down as a result: that would be the natural conclusion one might draw.
Well, a recent paper by Ashraf, Field, and Lee suggests otherwise in the case of Zambia. In a clever experiment that they implemented in a health clinic in Lusaka, they had two treatment arms (in addition to a control group who just received information): individual counseling, where women were counseled alone and given vouchers for free access to long-term and reliable methods of birth control (Depo-Provera and Jadelle); and couples counseling where the vouchers were physically handed to the husband.
Most of the paper is about the comparison of the two treatment arms (more on that below), but the answer to the question of increasing supply is answered by examining the outcomes in the couples counseling arm vs. the control group: while the take-up of different birth control methods were up 15 percentage points in the couples treatment arm, the prevalence of unwanted births was identical in the two groups. This suggests that the women who tried the new methods (mainly injectables and pills) were already managing to avoid unwanted pregnancies with the methods available to them before the intervention. The authors conclude:
“The policy implications of this comparison are straightforward. Increasing access while requiring spousal consent will not reduce excess fertility in settings like urban Zambia where modern contraceptives are already reasonably though by no means freely available. Though doing so is likely to change patterns of utilization towards more convenient and reliable long-acting methods, those positioned to take advantage of better access will be couples already in control of fertility through existing - and perhaps even traditional - methods. In sum, it appears that excess fertility in these settings is not driven by the high cost of birth control given that reducing direct and indirect costs had no impact on unwanted births. In contrast, evidence from our experiment indicates that technologies or policies that shift control of fertility from men to women are likely to reduce excess fertility and unwanted births, though with a welfare cost to men.”
The last sentence draws from the comparison of the individual vs. the couples treatments. The authors found that women who received counseling alone were 28% more likely to use a concealable form of contraception that led to a 57% reduction in unwanted births (defined as births to women who reported, at baseline, not wanting to give birth within the next two years). The authors suggest that most of this effect was due to women hiding the use of the voucher from disapproving husbands.
The paper is worth your read, not the least because it pulls off a difficult feat that has caused some tension in the IE field with the recent emergence of RCTs. Some papers reveal a previously unknown behavioral parameter using a clever experiment. Other papers try to address very policy-relevant questions while not necessarily providing any new insights into human behavior. But, only a small number of studies manage to do both and I feel that this paper is one of them. Not only do the results imply that there are substantial inefficiencies in the intra-household bargaining between husbands and wives who disagree on the number of total children they want (causing sub-optimal strategies for both), but also make the straightforward point that simply increasing the supply of reliable and long-acting birth control methods may not reduce unwanted pregnancies unless we also deal with the difficult issue of spousal consent.
Of course, this is only one study from Zambia. My colleague might still be right for many other settings. Do you know of any other studies that would suggest otherwise?
Next week, I plan to ruminate about speed dating as an instrument for marriage. After that, I plan to ponder whether running too many experiments will cause many development economists to burn out sooner than ideal. Stay tuned…
P.S. My friend and fellow blogger Jed Friedman, while commenting on a draft of this post, wrote to me that many studies find the demand for contraceptives to be highly price inelastic, suggesting that "unmet need" is not empirically supported. He pointed me to this paper by McElvey, Thomas, and Frankenberg and the literature cited therein.