---
title: "Adjusting unmet need for contraception by including husband’s virility in the Revised algorithm"
id: "plos-one-2-incorporating-husband-s-influence-in-estimating-unmet-need-for-contraception"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-2-incorporating-husband-s-influence-in-estimating-unmet-need-for-contraception"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392"
published_at: "2026-08-31T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Adjusting unmet need for contraception by including husband’s virility in the Revised algorithm
## Provenance & Clinical Metadata
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- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392)
- **Published At:** 2026-08-31T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- Unmet need for contraception (UNC) measures fecund, exposed women who want to limit or postpone childbearing but are not using contraception. It is widely used to guide family planning policy and resource allocation. - The standard **Revised algorithm** classifies women into met need, unmet need, no unmet need, and infecund/menopausal and is the accepted DHS approach for UNC estimation. - Scholars have argued some women labeled as having **unmet need for contraception** may genuinely have no unmet need due to partner-related factors that reduce conception risk. - This study proposes and implements a **modified Revised algorithm** that adds a constraint to reclassify exposed women whose husbands have diminished fecundity/virility as having no unmet need. - Husbands’ virility loss is attributed in the paper to genetic causes (e.g., azoospermia, aspermia, undescended testicles), health conditions (diabetes, cancers, STIs), social/psychological factors (stress, depression), and lifestyle or trauma factors. - Using 2014 Kenya Demographic and Health Survey (KDHS 2014) data, the authors selected 8,710 reproductive-age women meeting fertility criteria and applied the modified algorithm in Stata. - The **modified** estimate of unmet need was 16.4 percent—1.1 percentage points lower than the national (KDHS) estimate—implying an approximate 6.6 percent overestimation by standard methods. - Modified estimates were highest among adolescents, rural residents, and women in the Northeastern region, and declined with higher education and greater household wealth. - The study concludes that incorporating **husbands’ virility** into UNC measurement reclassifies some women from unmet need to no unmet need and recommends including virility loss when estimating unmet need for contraception. - Data were drawn from publicly available DHS data (requestable from the DHS Program); the authors reported no specific funding and no competing interests.
## Clinical Analysis & Structured Key Points
[ Skip to main content ](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#main-content) Advertisement * [plos.org](https://plos.org/) * [Create account](https://community.plos.org/registration/new) * [Sign in](https://journals.plos.org/user/secure/login?page=%2Fplosone%2Farticle%3Fid%3D10.1371%2Fjournal.pone.0357392) * * About * Browse * Publish * [](https://journals.plos.org/plosone/ "PLOS One") * Search [advanced search](https://journals.plos.org/plosone/search) * [Browse Topics](https://journals.plos.org/plosone/subjectAreaBrowse) Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click [here](https://github.com/PLOS/plos-thesaurus/blob/master/README.md "Link opens in new window"). [](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392) [](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392) * 0 [Save](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357392#savedHeader) [Total Mendeley and Citeulike bookmarks.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357392#savedHeader) * 0 [Citation](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357392#citedHeader) [Paper's citation count computed by Dimensions.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357392#citedHeader) * 53 [View](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357392#viewedHeader) [PLOS views and downloads.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357392#viewedHeader) * 0 [Share](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357392#discussedHeader) [Sum of Facebook, Twitter, Reddit and Wikipedia activity.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357392#discussedHeader) Open Access Peer-reviewed Research Article # Incorporating husband’s influence in estimating unmet need for contraception using modified revised algorithm * Gerald Mbuthia Mahuro , Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft * E-mail: gembuthia@gmail.com, gerald.mahuro@ksg.ac.ke Affiliations Kenya School of Government, Nairobi, Kenya, University of Nairobi, Nairobi, Kenya [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0009-0004-5867-7118 ](https://orcid.org/0009-0004-5867-7118 "ORCID Registry") ⨯ * Murungaru Kimani, Roles Supervision, Validation, Writing – review & editing Affiliation University of Nairobi, Nairobi, Kenya ⨯ * Andrew Kyalo Mutuku Roles Supervision, Writing – review & editing Affiliation University of Nairobi, Nairobi, Kenya ⨯ # Incorporating husband’s influence in estimating unmet need for contraception using modified revised algorithm * Gerald Mbuthia Mahuro, * Murungaru Kimani, * Andrew Kyalo Mutuku ![PLOS](https://journals.plos.org/resource/img/logo-plos-full-color.svg) x * Published: August 31, 2026 * * [Article](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392) * [Authors](https://journals.plos.org/plosone/article/authors?id=10.1371/journal.pone.0357392) * [Metrics](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357392) * [Comments](https://journals.plos.org/plosone/article/comments?id=10.1371/journal.pone.0357392) * [Media Coverage](http://plos.altmetric.com/details/doi/10.1371/journal.pone.0357392) * [Abstract](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#abstract0) * [Introduction](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#sec001) * [Evolution of measurement procedure](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#sec002) * [Materials and methods](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#sec003) * [Results](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#sec004) * [Discussion, conclusion and recommendation](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#sec005) * [References](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#references) * [Reader Comments](https://journals.plos.org/plosone/article/comments?id=10.1371/journal.pone.0357392) * [Figures](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392) ## Abstract Unmet need for contraception is defined as the proportion of exposed fecund reproductive age women desiring to limit fertility but who are contraceptive nonusers, and it has invaluable contributions to population dynamics policies besides engendering fertility discourses. Aligning with the continuous evolution of conceptualization, the fluidity of the robust measurement model was indispensable, stemming from a formula that identified a pool of reproductive age women in irrational situations, discrepant behavior, “KAP-Gap” and unmet need for contraception. Extant fertility literature suggests the possibility of some reproductive age women classified as having unmet need but genuinely have “no unmet” need. This study proffers that exposed women whose husbands have a virility issue attendant to genetic, health, social, and lifestyle factors may obliviously forgo birth control methods on the perception of reduced pregnancy risk. Upon incorporating husbands’ virility loss, this study generated a modified “Revised” algorithm and utilized 2014 Kenya demographic and health survey data to select 8,710 reproductive age women who met fertility criteria. Using Stata ® the modified “Revised” algorithm estimated unmet need for contraception at 16.4 percent, lower than national estimates by 1.1 percentage points, implying 6.6 percent overestimation. The “modified” estimates were highest among adolescents, rural dwellers, and residents of Northeastern region but decreased with increasing education and household wealth. This study has generated a modified “Revised” algorithm, confirmed overestimation of “unmet need” for contraception, incorporated overlooked husband’s virility loss, and proved reclassification of women from “unmet need” to “no unmet need.” These results, therefore, endorse incorporation of virility loss as a reason exuded by exposed reproductive age women for abstaining from birth control methods. ## Figures ![Table 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357392.t001) ![Table 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357392.t002) ![Table 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357392.t001) ![Table 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357392.t002) ![Table 1](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357392.t001) ![Table 2](https://journals.plos.org/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0357392.t002) **Citation:** Mahuro GM, Kimani M, Mutuku AK (2026) Incorporating husband’s influence in estimating unmet need for contraception using modified revised algorithm. PLoS One 21(8): e0357392. https://doi.org/10.1371/journal.pone.0357392 **Editor:** Mena Abdalla, King’s College Hospital NHS Foundation Trust, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND **Received:** July 14, 2025; **Accepted:** August 17, 2026; **Published:** August 31, 2026 **Copyright:** © 2026 Mahuro et al. This is an open access article distributed under the terms of the [Creative Commons Attribution License](http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. **Data Availability:** Third party data was obtained for this study from the DHS Program. Data may be requested from the DHS Program after creating an account and submitting a concept note. More access information can be found on the DHS Program website ( ). The authors confirm that interested researchers would be able to access these data in the same manner as the authors. The authors also confirm that they had no special access privileges that others would not have. **Funding:** The author(s) received no specific funding for this work. **Competing interests:** The authors have declared that no competing interests exist. ## Introduction Measurement and understanding of the aspects attendant to unmet need for contraception (UNC) has evolved to be an important area of demographic research due to its invaluable implications to policies regarding population dynamics and fertility discourses [[1](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref001)]. Unmet need for contraception refers to the proportion of exposed fecund women of reproductive age (WRA) within ages 15–49 years, who are desiring to reduce their fertility by either limiting or postponing childbearing despite being contraceptive nonusers [[1](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref001)–[3](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref003)]. Complimentarily, [[4](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref004)] summarized the concept of unmet need for contraception as the difference between the demand and need for contraception, while, [[2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref002)] described unmet need for contraception as the discrepancy between woman’s fertility desires and contraceptive behavior. Assuredly, a plenitude of literature postulates that estimates of unmet need for contraception is a representation of a pool of women who want to practice contraception but are letdown by diverse intrinsic reasons besides known inadequacies in access to family planning supplies and services [[2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref002)]. The concept of unmet needs for contraception is not without skepticism that emanated from divergent views, including inconsistent behavior of woman’s pregnancy prevention, underestimation of exposure to the risk of pregnancy, unpredictability of future use of contraceptives, besides inherent measurement and conceptual complexities [[2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref002)–[5](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref005)]. Interestingly, the unmet need for contraception is an invaluable and widely used concept for measuring how populations’ contraception needs are met, and reveals the size of the potential unfulfilled demand for family planning [[2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref002),[6](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref006)]. Several studies have concluded that, reducing unmet need for contraception is responsible for enhancing social, cultural and economic autonomy of women through attainment of preferred family size, improved livelihood, and reduced lifetime fertility [[7](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref007),[8](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref008)]. The impact of UNC on fertility decline is multipronged because improved contraceptive use is associated with a decline in unmet need for contraception [[1](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref001)] whereas increased contraceptive use is a known major contributor of fertility decline [[2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref002),[4](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref004)]. Based on this symbiotic relationship, unmet need for contraception depicts a negative relationship with contraceptive use, and therefore UNC is construed as a proxy measure to reduced lifetime fertility. This has led to extensive and careful examination of unmet need for contraception to the extent of attaining equal stature with contraceptive use. This has elevated UNC to be considered as: A cardinal global justification for increasing resource allocation; evaluating Country’s family planning policies and programs on meeting populations’ felt need; monitoring achievement of sustainable development goal 3.7.1; a hypothetical link between population growth concerns and women’s ability to practice reproductive rights at own volition; and, a valuable link between human rights and feminist approach on matters fertility regulation and demographic dividends [[2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref002)–[4](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref004),[9](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref009)]. Understandably, the current ‘Revised’ algorithm is widely accepted as the standard approach in estimating unmet need for contraception, culminating into classifying reproductive age women into four categories of; met need, unmet need, no unmet need and infecund/ menopausal. In this context, [[10](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref010)] argued that there is a possibility of existence of a pool of exposed women of reproductive age who have been classified as having unmet need but they genuinely have no unmet need for contraception. This study corroborates this argument by proposing that there exists a pool of exposed women of reproductive age whose husbands suffer virility issues, thereby portending reduced risk of conception, notwithstanding coital interaction. Appreciating the multi-decade efforts geared towards improving this “Revised” algorithm which was declared by scholars as “irreplaceable in unforeseeable future” [[2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref002)], scholarly scrutiny is indispensable. In extending this discourse, this study incorporates the overlooked husbands’ effect by generating a modified “Revised” algorithm that provides estimates of unmet need for contraception that are expected to be lower, therefore proffering overestimation of KDHS 2014 estimates. The husbands’ effect in this context is the diminished fecundity that may be attendant to loss of virility, which medically emanates from genetic, health, social and lifestyle factors. The genetic factors include; azoospermia- No measurable sperm from the fluid ejaculated during orgasm (semen) and this is prevalent in one percent of all men [[11](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref011)], aspermia – complete absence of semen from ejaculate – dry ejaculate [[12](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref012)], undescended testicles, and other genetic defects). The health problems may include diabetes, testicular or prostate cancer, sexually transmitted infections, chronic disease whereas the social problems include stress, depression and hormonal imbalance. Finally, the lifestyle factors include habituation, asexual and trauma [[13](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref013)–[15](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref015)]. Such reasons expressed by a pool of exposed woman of reproductive age as a justification for not using contraception despite having coital interaction are usually analyzed using the “Revised” algorithm as “unmet need” for contraception. In essence, women who are in such situations have a high likelihood of developing a genuine feeling of “superficial protection” and thus portend a reduced risk of pregnancy. To this end, this pool of exposed reproductive age women genuinely qualify to be considered as having “no unmet need” for contraception. This consideration appraises the fact that some exposed fecund women of reproductive age being consciously aware of reduced/ no risk of conception attendant to husbands’ virility issues, may obliviously decide to abstain from any contraception use. This study therefore operationalizes this argument by developing another constraint for inclusion in the “Revised” algorithm to develop the modified “Revised” algorithm that generates “Modified” estimates of unmet need for contraception. Upon incorporating this husbands’ virility aspect in the “Revised” algorithm to cater for overestimation, the emerging evidence will guide in designing the UNC as best estimator of total fertility rate besides allocating optimal resources for family planning programs, globally. ## Evolution of measurement procedure As the conceptual definition of unmet need for contraception gained attention in fertility discourses thus becoming confounded, concurrently, demographers, family planning practitioners and researchers developed ideas bespoke precise measurement procedures. The inaugural quantification was made by [[16](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref016)] who used data from three Knowledge, Attitudes and Practice (KAP) surveys conducted in Taiwan in 1965 (KAP-I), 1967 (KAP-II) and 1970 (KAP-III). In each of these KAP surveys, a probability sample was randomly selected to represent all married women of reproductive age as survey respondents. In attempting to conceptualize the formulae used in computing this pool of women, let ![](https://journals.plos.org/plosone/article/file?type=thumbnail&id=10.1371/journal.pone.0357392.e001) be number of married women who are contraceptive nonusers, ![](https://journals.plos.org/plosone/article/file?type=thumbnail&id=10.1371/journal.pone.0357392.e002) be number of married women who want no more children, ![](https://journals.plos.org/plosone/article/file?type=thumbnail&id=10.1371/journal.pone.0357392.e003) be married women aged 22–39 years and ![](https://journals.plos.org/plosone/article/file?type=thumbnail&id=10.1371/journal.pone.0357392.e004) be the intersection of elements that belong to unique sets as stipulated in Set Theory. The proportion of married women who were not using contraception and who wanted no more children can be derived by the general formulae ![](https://journals.plos.org/plosone/article/file?type=thumbnail&id=10.1371/journal.pone.0357392.e005). Further, the pool of women “who were married who were contraceptive nonusers, who wanted no more children”, can be simplified as ![](https://journals.plos.org/plosone/article/file?type=thumbnail&id=10.1371/journal.pone.0357392.e006), and thus termed as being in an irrational situation. Further examination of women in “irrational situation” was done by [[17](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357392#pone.0357392.ref017)] who extended the analysis by adding two more KAP surveys that were conducted in Taiwan in 1971 and 1973. The estimation used a unique time series technique based on the concept of a function of two components that included percent of “women who wanted no additional children and percent who were contraceptive nonusers” among those who wanted no additional children. Similarly, to operationalize this formulae, let
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