since the mid-1960s hundreds of national surveys have documented the historic rise in 
 contraceptive use . on average , use has grown at about one percentage point a year , or 10 
 percentage points in ten years ( for example from 30% to 40% of married / in union women of 
 reproductive age using contraception ) . for the developing world as a whole
, use has grown to 
 exceed 60% of married / in union women of reproductive age ( un population division , 2011 ) .
the types and variety of methods available to large populations are among the determinants 
 of contraceptive use .
since then , the contraceptive landscape has been transformed with the appearance of the iud , 
 the pill , simpler sterilization , improved condoms , and later , the injectable .
existing 
 methods have been improved ( e.g. low dose and progestin - only pills , and various types of 
 iuds and implants , and delivery systems for injectables ) and new methods are on the horizon . 

while the main methods theoretically spread through family planning programmes in much of 
 the developing world , some countries in fact still make only a minimum of contraceptive 
 choices available to their general populations .
pakistan and the philippines make only the 
 pill and condom available to over half of the population . in africa
, nigeria makes no method 
 except the condom available to over half of the population ; in most sub - saharan african 
 countries the pill and condom are the main methods offered to most people , and they suffer 
 from high discontinuation and pregnancy rates ( based on data from the 2009 round of the 
 family planning effort scores , explained below . )
the purpose of this paper is to specify the relationship between access to a range of 
 contraceptive methods and the use of those methods .
the relationship is examined from a 
 variety of perspectives , through multiple analyses , and across different years , 
 contraceptive methods and regions .
the analysis uses evidence of access and use for six 
 contraceptive methods and for the years 1999 , 2004 and 2009 , with some comparisons of 
 sub - saharan african countries with countries from other regions , totalling more than 60 
 countries .
much of the literature on the relationship between access to contraception and its overall 
 use focuses on the effect of adding one or methods to the previous mix .
the reasoning for 
 these studies is that after many decades of improvements in contraceptive technology , no 
 single method has emerged that satisfies all needs .
each method has its own shortcomings : it 
 is not reversible , it carries unpleasant side - effects , it is costly , it requires a clinical 
 vaginal procedure , or it conflicts with religious tenets . however , each method does work for 
 some women and couples ; therefore each method added can serve another subgroup in the 
 population and add to total use .
numerous studies from the early experience of developing countries support the link between 
 easier access to contraception and the greater use of it .
freedman & berelson ( 1976 ) showed that during the early emergence of national 
 family planning programmes , the addition of each new method raised total contraceptive use . 

in korea in 1964 the iud was added to the national programme through the network of private 
 physicians , and within three years one in eight married / in union women were using it , more 
 than replacing a decline in traditional methods , while other modern methods remained 
 constant ( kim & ross , 2007 ) . in thailand
the 
 ministry of public health in 1970 added the pill to the family planning programme through 
 the national network of auxiliary nurse midwives ; its use rose rapidly to 20% of married / in 
 union women and by 1975 one in seven married / in union women were using it , double that of 
 the pre - existing methods ( rosenfield & min , 2007 ) . in egypt in 1985 regulatory constraints to iud provision were removed and the 
 new copper - t iud was introduced . within four years
its prevalence of use doubled , from 8% to 
 16% ( robinson & el - zanaty , 2007 ) .
additional national and local studies have found links between access and use . in colombia , 

korea and malaysia use declined regularly according to the perceived travel time to a clinic 
 ( rodriguez , 1978 ) . in thailand , use increased 
 according to the number of different sources of contraception in villages , reducing travel 
 time to the nearest one ( chamratrithirong & kamnuansilpa , 1984 ) . in mexico and rural korea ,
national survey data showed use to be 
 greater where women believed contraceptive services to be readily available and lived in 
 areas where contraceptive outlets were located nearby ; moreover , unmet need was less ( tsui , 
 1982 ) .
a study of four philippines towns 
 concluded that increasing clinic density would put services closer to more people and 
 greatly reduce the average distance for clients ( lynch & aganon , 1974 ) .
successive concentric bands , lying farther from 
 a health centre , have larger diameters and contain larger areas and populations ; therefore 
 more outlying service points are needed to keep travel time down .
a comparison of 21 
 countries participating in the world fertility survey showed travel distances and time to 
 vary sharply among contraceptive methods ( jones , 1984 ) .
a study of 36 countries with 1982 national data found use to rise from 10% to 
 over 60% as the number of available modern contraceptive methods increased from none to 56 
 ( lapham & mauldin , 1985 ) .
these various 
 results were consistent with the 1971 simulation study by robert potter ( 1971 ) on the limitations of a single method , 
 demonstrating that the normal duration of use of the iud alone , even allowing for 
 reinsertions , left many women with no alternative protection for the reproductive years 
 remaining , apart from multiple abortions .
jain ( 1989 ) extended that work to show that india 's 
 heavy reliance on sterilization would be inadequate to reach its goal of a 2.1 total 
 fertility rate by 2020 without extending its use unrealistically into young age groups . by 
 broadening the method mix
( 1994 ) obtained a very similar result for india using a computer simulation of 
 alternative method mixes .
( 1989 ) in a volume devoted to 
 determinants of contraceptive choice in asia and the united states . in work on taiwan , jain ( 1989 ) noted the large 
 increase in total duration of contraceptive use when multiple methods were considered . at 30 
 months after an iud insertion ,
the percentage still using the iud , including reinsertions , 
 was 47% , but an additional 26% were using other available methods after giving up on the 
 iud .
he extended the original freedman and berelson work to show that , with 1982 data , the 
 widespread addition of one method would raise contraceptive use by about 12 percentage 
 points ( e.g. from 30% to 42% using ) , based upon the correlation across countries between an 
 access index and prevalence of use .
choe & bulatao ( 1992 ) stressed differences in the mix of methods according to life stage , from 
 before marriage to the interval between marriage and first birth , then between births , and 
 finally after the last birth .
the actual method mix found in survey information for nepal 
 and indonesia showed shortfalls both in use and in the numbers of unplanned births resulting 
 from distortions in the mix . an important analysis by sullivan et al . 

they defined a skewed method mix as a single method constituting 50% or more 
 of all contraceptive use in a country .
of 96 countries , 34 had a skewed mix : sixteen in 
 which traditional methods dominated , most in sub - saharan africa ; four in which female 
 sterilization dominated , in india and three in latin america ; and fourteen that relied 
 either on the pill , or iud , or injectable , spread over various regions .
reasons for 
 distorted method mixes are multiple , including poor access to a broad range of methods . for the developing world in general , darroch et al .
( 2011 ) have assessed the potential for reducing unmet needs for 
 contraceptive use , given improved options among contraceptive choices .
they stress that even 
 when improved methods are available they suffer from such defects as side - effects , or the 
 necessity for partner compliance and medical services .
better contraceptive technology is 
 needed both to improve current methods and to develop new ones .
they estimate that if 
 method - related reasons for non - use of modern contraception were overcome , unintended 
 pregnancies could be reduced by as much as 59% in sub - saharan africa and south - central and 
 south - east asia . the overall relationship between access and contraceptive use , employing ratings of 
 contraceptive access together with measures of contraceptive use , by method , was explored by 
 ross et al .
the present 
 article provides an updated analysis of several features of that study by using the 1999 , 
 2004 and 2009 rounds of the family planning effort scores , described below .
all rounds of 
 the family planning programme effort scores measured access to the iud , pill , male and 
 female sterilization and the condom .
the 2004 and 2009 rounds measured access to the 
 injectable , separately from the pill ; previously the injectable was used less by women and 
 so was merged with access to the pill .
a word is required as to the meaning of  contraceptive access. whether a variety of method 
 choices are easily available to a woman or couple depends upon the physical closeness of a 
 site for each method and upon low cost .
in addition , the absence of barriers is important , 
 and they can be multiple : regulations against young or unmarried women for any method , or 
 against women with no or few children ( for sterilization ) ; repeated clearances by 
 obstetricians / gynaecologists or general practitioners ; long waiting lines ; supply outages ; 
 and social awkwardness , as when women obtain condoms .
empirical measures for these obstacles vary , and no single one 
 can capture them all . however , a single measure of access to contraception has been used in a time series running 
 from 1972 to 2009 , for over 80 countries , and it is used here to test the relationship of 
 actual contraceptive use to access defined broadly .
it is necessarily approximate , as a 
 trade - off for nearly universal coverage of the developing world , using a common 
 questionnaire over a long time period .
it relies on the assessments of local experts who are 
 in a position to judge the proportion of the entire population having  ready and easy 
 access to each contraceptive method .
this is regardless of source , so it covers both 
 private and public sectors , and both clinical and non - clinical outlets .
sources include 
 static facilities , social marketing through partially subsidized sales , community - based 
 depots and home delivery , and in some countries contraception is offered at the time of 
 delivery or post - abortion care .
disadvantages include the judgmental nature of ratings by 
 expert observers , though that affords measures on variables not otherwise available .
an alternative approach to exploring the access  use relationship uses data from a sample of 
 facilities to gather information on methods offered , with linkages at some geographic level 
 to contraceptive use as given in household surveys .
2012 ) despite the 
 limitation of dissimilar sampling designs that require aggregation of results at regional or 
 other levels .
the analyses in this paper come from two sources of information : first , contraceptive use 
 information is taken from the demographic and health survey series ( macro international , 
 2011 ) and from the united nations compilation ( un 
 population division , 2011 ) , which provides 
 additional national surveys .
second , information on access to contraception by national 
 populations comes from the 1999 , 2004 and 2009 cycles of the national family planning 
 programme effort studies , each cycle covering more than 80 developing countries .
these 
 studies have been reported on extensively ( ross & smith , 2011 ) ; they gather information on each national programme through a 
 standard questionnaire administered to expert observers in each country .
these respondents 
 are asked to estimate the proportion of the national population that has 
ready and easy 
 access to each of six contraceptive methods plus safe abortion , along with ratings for 
 eight policy variables , thirteen services variables and three evaluation variables , 31 in 
 all .
additionally , responses are obtained for a set of judgments concerning programme goals , 
 the effect of funding changes , and other items of interest .
all large countries are included 
 in each year ( china , india , bangladesh , pakistan , and indonesia in asia , mexico and brazil 
 in latin america , nigeria in africa , and nearly all middle - sized countries in each 
 developing region ) .
modern method : male and female 
 sterilization , the iud , the pill , the injectable and the condom .
 traditional methods of 
 rhythm and withdrawal are omitted as they do not require services and supplies .
the 
 percentage of the whole population judged to have access to each modern method gives the 
 basic data used below . depending upon the analysis the focus is upon either the individual 
 method or the average across methods .
the access measures are compared with the prevalence measures , i.e. the proportion of 
 married / in union women or couples who are currently using each of the above methods , as 
 obtained in nationally representative surveys .
the access studies are in fixed years ( 1999 , 2004 and 2009 ) , so the 
 household surveys taken closest to those dates are employed for each country .
the selection of methods below uses a variety of approaches to examine the access  use 
 relationship .
the basic rationale , as explained above , is that because the available 
 contraceptives are so different from one another and because each one has its own particular 
 set of strengths and shortcomings , each one will attract its own subset of users .
therefore , 
 total use will be greater where more methods are made readily accessible to the general 
 population .
each table or chart below applies a different approach to the nature or 
 closeness of the access  use relationship .
while the possibility can not be excluded of some 
 circularity in the relationship whereby questionnaire respondents who rate access are 
 influenced by some sense of the degree of use in the country , the systematic patterns 
 reported below appear to go well beyond that , differentiating the results beyond a simple 
 overall correlation .
in addition , for some analyses in the paper , sub - saharan africa is considered here 
 separately from other regions , and a 19992009 time trend is given for access to multiple 
 contraceptive methods .
the results reported below focus first on the average relationships between access and use 
 in each of the years 1999 , 2004 and 2009 , followed by the regional difference between 
 countries in sub - saharan africa and those elsewhere . then the access  use relationship is 
 examined for each contraceptive method separately as of 2004 ( when there are more data from 
 surveys than in 2009 ) .
next , the relative positions of the methods are examined to show the 
 contrasts under low access vs high access . finally , the degree of access to multiple methods 
 in the same country is examined . a first way to examine the dependence of contraceptive use upon
1 . it compares , for each year , the average 
 access rating with the average rating for the prevalence of use . 
mean access includes 
 the iud , pill , female sterilization and condom in 1999 , and those methods plus the 
 injectable in 2004 and 2009 , when it became more widely available in programmes .
mean 
 prevalence denotes the percentage of married / in union women using those methods , taken 
 from national surveys conducted within one to three years of the date of the effort score . 

1.comparison of mean contraceptive access rating with mean prevalence rating , by 
 year . 
 
comparison of mean contraceptive access rating with mean prevalence rating , by 
 year . for 1999 and 2004
there are 67 and 63 countries respectively that have information on 
 both mean prevalence and mean access ; for 2009 there are only 32 due to lack of prevalence 
 surveys on or near 2009 since few surveys were available for exactly 2009 or in 20102011 . 
 in each of the three years 1999 to 2009
the relationship is consistently positive ; in fact 
 the relationship becomes stronger with time .
not only do the correlations between mean 
 access and mean use progress from 0.30 to 0.31 to 0.45 , the slopes also sharpen from 0.18 
 to 0.21 to 0.25 , meaning that in 2009 , a 10-point increase in the mean access score 
 translated into an increase of 2.5% in mean contraceptive use .
( 2002 ) found very similar results for patterns in 1982 , 1989 and 1994 , as well as 
 1999 , for the same contraceptive methods except the injectable , for which separate data 
 were not gathered in those years .
thus the positive relationship between access to 
 contraception and contraceptive use has persisted over nearly three decades . as access 
 ratings across various methods have improved to give more options to more couples , total 
 use has increased .
an important regional difference exists in the overall averages , illustrated by the 2004 
 data in fig .
2 . it compares the 30 sub - saharan 
 africa countries with the 35 countries in other regions .
the sub - saharan africa countries 
 are clustered toward the left of the figure , at lower access levels ; in fact none falls 
 into the highest access range of 68% and above ( to 84% , the highest recorded ) .
moreover , 
 at each of the other three levels of access , the average prevalence in sub - saharan africa 
 is well below that of the other countries .
francophone countries are especially 
 disadvantaged : prevalence is constrained at a low level even though access varies 
 appreciably . among all 30 sub - saharan countries ,
23 are below 20% prevalence , and eleven 
 francophone countries are below 10% prevalence ( data not shown ) .
overall prevalence rises rather sharply across the access range shown in both groups of 
 countries : from 9.4% to 22.7% in sub - saharan africa compared with an increase from 17.9% 
 to 57.8% elsewhere . over time , a shift of more african countries toward higher access 
 levels should bring with it higher prevalence levels as well , although additional research 
 is needed to examine the reasons for the difference in mean contraceptive prevalence at 
 the same level of access in sub - saharan africa compared with other countries .
it is likely 
 that other programmatic or demand - side factors are driving the differences .
an additional perspective on the relationship between access and use focuses on the 
 individual contraceptive methods ( fig .
3 keeps 50% as the 
 maximum for use ( the y - axis in each chart ) in order to highlight the 
 range differences among methods . the access  use relationship is positive for each method , 
 but with significant variations .
three methods  the pill , iud , and female sterilization  
 show substantial slopes , between 0.31 and 0.39 ( the latter meaning that a 10-point 
 increase in access yields an increase of 3.9% using the method )
. however , the slopes are 
 weaker for the injectable and the condom ( see table 
 1 ) .
the condom may be a special case since the data pertain to married / in union 
 women , for contraceptive purposes only , and condom use would be greater by including use 
 for hiv prevention and among unmarried women .
it is possible that reported condom use for 
 contraception is depressed , not only due to respondent shyness to mention it , but also due 
 to some stigma from its association with hiv . fig .
3.continued 
 table 1.slope of access  use relationship for different contraceptive methods , 2004slope 
 r 
 pill0.310.26iud0.390.44female sterilization0.360.41injectable0.170.20condom0.110.06 
  relationship of contraceptive prevalence to access , by method , 2004 .
slope of access  use relationship for different contraceptive methods , 2004 the iud and female sterilization show high correlation values , indicating that use 
 follows access more closely than with the other methods
. however , use levels are 
 universally far below access levels , which is as expected
. a particular method may be 
 readily available for many women or couples but they prefer a different method or are not 
 using anything at all .
access is a necessary but not a sufficient condition for the use of 
 a method . for all five methods some countries are outliers , high and to the right
this reflects 
 the marked geographic pattern that characterizes programmes and the methods that are both 
 accessible and popular within them . for the condom , ukraine and jamaica
show the highest 
 values ; otherwise the cluster of points rests lower for percentage using than for any 
 other method .
the injectable takes high values in east and southern africa , in some latin 
 american countries , and in indonesia and thailand ; but it is a minor method elsewhere 
 ( ross & agwanda , 2012 ) .
the iud is nearly 
 absent in sub - saharan africa but is prominent in the middle east and north africa .
female 
 sterilization is absent in the middle east and north africa but is important in latin 
 america .
condom access is rated quite high nearly everywhere but the actual use levels are 
 low .
ideally , access should be good for several methods , at a uniformly high level , so that 
 the variability among methods is low .
but 
 variability can also be low when access is uniformly poor for all methods ; in that case 
 prevalence should be low .
therefore , it is important to know both the level and the 
 variability of access , and to relate those to prevalence .
table 2 examines the prevalence of use as the 
 sum across all methods , shown by country .
sixty - four countries are classified according to 
 both level and variability of access in 2004 . cutting points in the table cast about half 
 of all countries into each column and about half into each row .
variability is measured by 
 the standard deviation across access ratings for the various methods , and the access 
 level , either low or high , uses the median rating .
countries are grouped into four cells : 
 low access and low variability ( upper left cell ) , low access and high variability ( upper 
 right cell ) , high access and low variability ( lower left cell ) , and high access and high 
 variability ( lower right cell ) .
most countries fall into the upper right and lower left 
 cells , for either low access with high variability or high access with low variability . 

within each cell , the countries are listed in order of their total prevalence of use 
 ( exclusive of traditional methods ) .
table 2.contraceptive prevalence for 64 countries classified by high / low access and 
 variability , 2004variability of accessaccess levellowhighlowcongo , dr5.8chad1.6madagascar16.3liberia10.3guinea4.0haiti21.7yemen13.1niger4.9armenia23.6uganda17.4mauritania5.2cambodia25.3tanzania19.0nigeria6.6georgia25.7philippines32.8burundi8.5zambia26.2guatemala33.4rwanda8.8myanmar31.3indonesia51.8gambia8.9bolivia32.2uzbekistan59.0cameroon12.1peru46.0dominican republic64.7azerbaijan12.9india47.4ethiopia13.6median25.9median13.6highmozambique11.8honduras55.8benin5.3ghana16.8viet nam56.1mali6.2pakistan21.7ecuador57.8burkina faso7.3lesotho35.2paraguay60.3togo9.0jordan38.3el salvador60.8senegal9.3turkey41.8colombia65.0malawi27.7turkmenistan45.0mexico65.1nepal37.1bangladesh46.3nicaragua68.4morocco51.8swaziland46.5thailand69.1namibia52.7ukraine46.9china83.1egypt55.7zimbabwe56.6south africa59.6jamaica66.0median51.4median37.1 
  contraceptive prevalence for 64 countries classified by high / low access and 
 variability , 2004 as expected , median contraceptive prevalence is highest where access is high , at 51% and 
 37% in the two cells on the bottom row ( prevalence is 46% for the two cells merged ) . 

contraceptive prevalence is much lower where access is low , in the top row , at 26% and 14% 
 ( 17% merged ) .
similarly , prevalence is considerably higher where variability is low indicating fairly 
 uniform levels of access among the several methods . that might offer greater choice among 
 methods ;
however , uniformity across the methods can occur with either low or high access 
 levels .
given low variability ( two left cells ) , greater access makes a large difference , 
 doubling the prevalence level : 26% compared with 51% ( 43% merged ) .
the relationship holds 
 in the second column for high variability : prevalence averages a very low 14% if access is 
 poor with more than a doubling to 37% where access is good ( 23% merged ) .
overall , 
 prevalence ranges from only 14% using to about half ( 51% ) using , depending upon the blend 
 between average access to contraceptive methods and average variability among the five 
 methods .
clearly the best combination is good access with an even - handed treatment of the 
 several contraceptive options .
why , 
 for example , is indonesia in the low access row while mozambique is in the high access 
 row ? actually , both lie close to the 59% cut - off rule for mean access that creates the two 
 rows , with indonesia at 57% and mozambique at 62% .
both countries have low ratings for 
 access to female sterilization , and high ratings for access to the pill and injectable , 
 but mozambique is considerably higher for the condom , probably due to the aids programme 
 in the country .
pakistan barely enters the high access group , at only 58% average access , 
 and measurement error can be present in particular country ratings . a different approach to understanding the comparative pictures of contraceptive access 
 and contraceptive prevalence for the various contraceptive methods
figure 4a shows in each bar the distribution of access for each of the five 
 methods . as overall access improves ( along the bottom axis ) , the relative positions of the 
 various methods shift . at the left , where average access is limited to 43% or less of the 
 population , condom access is best , with pills second . at the other extreme , where average 
 access is 71% or higher , the balance among methods is better : access to condoms is 
 relatively lower while access to female sterilization and the iud is relatively higher . 
 over past decades , actual access for all methods
has in fact been improving ; meanwhile 
 their relative positions have been changing , toward a closer balance of choices offered to 
 the population .
4.percentage distribution of contraceptive access ( a ) and prevalence ( b ) , by method , 
 according to mean level of access , 2004 . 
 
percentage distribution of contraceptive access ( a ) and prevalence ( b ) , by method , 
 according to mean level of access , 2004 .
figure 4b goes farther to show in each bar the 
 distribution of prevalence for the five methods .
4a : the relative position 
 of condom use declines considerably while that of female sterilization increases quite 
 sharply .
the injectable is about as important as the pill , except in 
 countries with the highest overall access .
while the condom loses 
 share , the original data show an increase in the absolute percentage using it .
in fact , 
 use of every method shown rises as total prevalence of use rises .
figure 5 displays this ; it divides the range of total use into four 
 equal intervals on the x - axis , with each bar showing the percentage of 
 married / in union women using each method .
( the rightmost range ends at 83.1% but that is 
 for china , an outlier .
sterilization gains the most , and each of the other methods gains at 
 each level , including the injectable at the top .
4 is the emergence 
 of a better balance among the five methods as access improves , with a corresponding 
 improvement in the balance for actual use of the methods . that balance is consistent with 
 a wider choice for clients .
the data show the manner in which the pool of users tends to 
 move toward a variety of methods as more options are made available . again
, note that the 
 figures show only the relative positions of contraceptive use as access improves ; the 
 absolute level of use for each method generally rises with better access .
the focus on personal choice among contraceptive options requires attention to 
 combinations of methods , not just to any single method .
it is possible from the access 
 data to examine access to multiple methods in various combinations ( table 3 ) . for this analysis ,
the rule is that at least half of the 
 population must have access to a method for it to be considered available in any of the 
 combinations shown .
table 3.percentage of population with access to multiple contraceptive methods 
 199920042009condom90.896.498.8pill83.990.491.4iud48.345.845.7female sterilization42.527.730.9male sterilization17.24.87.4injectablena67.569.1pill , iud47.142.244.4pill , female sterilization42.525.330.9iud , female sterilization33.318.124.7pill , iud , female sterilization33.315.724.7pill , iud , female sterilization , condom32.215.724.7at least one long - term method57.555.453.1at least one short - term method93.197.698.8at least one long - term & one short - term 
 method57.555.453.1ato protect the time trend the injectable is not included in the combinations.access rule : 50% or more of the population has access to the method . 
 
percentage of population with access to multiple contraceptive methods 
  to protect the time trend the injectable is not included in the combinations .
the first panel in the table sets a baseline ; it shows the limiting effect of each method 
 when included in any combination below .
for example , because female sterilization was 
 available in only 31% of countries , no combination including it below can rise above 31% . 

a consistency across the years is evident : in the first panel the rank order of methods 
 does not change annually . in 1999
the condom comes first , then the pill , then the iud , 
 then female sterilization , and finally male sterilization . in 2004 and 2009 the injectable 
 was included and it took third place .
the injectable is excluded in the combinations that 
 follow to maintain the time trend for a full decade .
male sterilization is also excluded , 
 since its low value would force a low value on any combination involving it .
any 
 combination with the iud can rate at most 46% to 48% , which is the case for its 
 combination with the pill : the values of 42% to 47% are slightly below those of the iud 
 alone since the pill , while widely available , is lacking in some countries .
the last three 
 rows in the middle panel are quite similar and take the lowest values due to the double 
 constraints of female sterilization and the iud .
finally , the bottom panel permits more flexibility : the first row allows for a country to 
 have either the iud or female sterilization , and the second row permits either the pill or 
 the condom to qualify .
the last row reflects the limit due to the inclusion of the first 
 row rules .
these results make it clear that many countries fall short in offering multiple methods . 

most countries offer at 
 least the pill or condom or both , and that high figure would be yet higher if the 
 injectable were included as well .
however the rule is  at least one , and where it is only 
 one the choice of options is unsatisfactory for many potential users .
similarly , where  at 
 least one short - term method and one long - term method means only one of each , that is 
 inadequate for the general population .
the findings in this report extend and expand those in the analysis from ten years ago that 
 used similar methods and data sources .
putting the two together gives a 27-year span of 
 experience , from 1982 to 2009 , for the dependence of contraceptive use upon the degree of 
 access to a range of contraceptive methods .
use relationship in 
 each of the six years examined ( 1982 , 1989 , 1994 , 1999 , 2004 and 2009 ) based first upon the 
 mean levels of both access and use .
next , this result is reinforced with breakdowns of the 
 means across ranges of both access and use .
in addition , prevalence of use is highest in 
 countries where both the mean level for access is high and the variability among methods is 
 low , which together provide a wide choice of options to the population .
further , where the 
 overall level of access is high , methods are in better balance in their relative 
 accessibility and relative use .
however , the absolute levels of access show that most countries have far to go in actually 
 offering multiple methods for both long - term and short - term alternatives . in practice , few 
 countries have come close to making even four methods fully available to everyone .
whatever 
 the reasons , there is a sharp selectivity in which methods are present .
access varies not 
 only by method , but by local areas within each country and by source of supply .
not everyone 
 in a country has the same access to each method and to each source .
the extent of these 
 disparities is not well documented and deserves much more attention , especially in 
 individual country studies .
various new methods that have been tested have failed for a variety of reasons to win a 
 substantial following after pilot trials , so the experience of the past decades is that most 
 use is of just six modern methods : the pill , injectable , iud , male and female sterilization 
 and the condom ( leaving traditional methods aside ) .
every country has been selective within 
 that group , concentrating on as few as one or two methods .
others have a balance among three 
 to four methods , but that is uncommon .
new methods face challenges in being scaled up to 
 ensure wide access for full national implementation . in general , because each method has its own particular blend of advantages and weaknesses 
 it finds its own subgroup of users , therefore total use increases with the number of methods 
 made available to the population at large .
a wider choice of options leads to greater 
 overall use and to easier avoidance of unintended pregnancies . because none of the current 
 methods can serve all needs among all users a variety of methods fits a wider variety of 
 needs .
inevitably the access level will always be higher than the use level for a method , since 
 some persons prefer to use a different method or no method .
a partial exception to this is 
 sterilization since the use level cumulates from many past years , in each of which access 
 may have been low .
finally , prevalence of any method is not a function only of access . given 
 reasonable access to a method
, its use will fall below the access level and will depend upon 
 competing methods , provider influences , personal likes and dislikes among potential users , 
 and the experience of past users pro and con regarding the method 's appeal vs such negatives 
 as side - effects , health concerns and cost .
the analyses here pertain to a limit on what 
 prevalence can become , based on the public 's opportunity to obtain the methods .
raising 
 those limits can both enhance personal options for protection against unplanned pregnancy , 
 and reduce unmet need in the population at large .
the results here support policy and 
 programme decisions to make a wider range of contraceptive methods available and to extend 
 access to them throughout the country .
 summarysurvey data on contraceptive use for about 80 countries are related to measures of 
 contraceptive access , by method , from 1999 to 2009 . 
 cross - tabulation and correlational 
 methods are employed , with geographic comparisons and time trends . 
 total prevalence of use 
 for five modern contraceptive methods correlates well to a variety of access measures . 
 
 greater access is also accompanied by a better balance among methods for both access and 
 use . 
 sub - saharan african countries show similar patterns though at lower levels . improved 
 access to multiple methods 
 is consistently associated with higher levels of contraceptive 
 use . 
Introduction
Methods and Data Sources
Results
Discussion