Strengthening Integrated Approaches for Family Planning and Menstrual Health

Rationale for FP-MH Integration

Many linkages exist between FP and MH, but they are often underappreciated or ignored, and the fields have, for the most part, remained siloed.⁴ This is unfortunate because the sectors share goals and areas of work, serve similar populations, and have the potential to learn from and enhance each other.⁵ Both FP and MH operate under the larger umbrella of sexual and reproductive health and rights (SRHR), and both emphasize the importance of body literacy, bodily autonomy, choice, and self-care. Both fields have a shared goal to improve the health, well-being, and dignity of women, girls, and other people who menstruate and can face challenges of stigma, misinformation, and navigating complex social and gender norms. They both struggle to reach people across the reproductive life course, with MH sometimes being criticized for focusing too narrowly on adolescents and ignoring the needs of older menstruators, while country-level FP services often focus on those who are post-adolescent or in the middle of life and can struggle to reach adolescents. While this is true for the sectors on a conceptual level, MH is a much younger field that does not have the reach of the more established field of FP. Integrated approaches could help address these challenges and increase the reach and impact of both fields. Insights can be gained from other fields of health integration, including FP-HIV^6,7 and FP-immunization⁸ (Box). These insights were considered in the design of the programmatic guidance we describe later and have been used to develop the following formal definition of FP-MH integration:

The integration of FP and MH ensures that both FP and MF commodities and services are provided under a single programmatic umbrella, which may include both same-day, co-located services and referral-based approaches. “Services” refer to a wide range of programmatic elements, including training, education, counseling, advocacy, social behavior change communication, and access to products, facilities, resources, and care.

1. Improve Education and Awareness

Due to gender inequality and harmful gender norms that exist in most spaces, stigma and misinformation can impact both the FP and MH fields and can, in part, be addressed through educational outreach and dissemination of correct and accessible information (Table 1).^9–16 This includes using evidence-based curricula and teaching methods, such as comprehensive sexuality education,^9,17 to provide information about FP and MH, including information about the menstrual cycle and how it relates to pregnancy and fertility. A growing body of evidence suggests that providing young people with age-appropriate comprehensive sexuality education improves their ability to communicate to family members and health care providers about reproductive health and more easily access services such as FP later in life; this includes an increased ability to negotiate for safer sex and increased control over pregnancy planning and prevention.^18,19 Additionally, puberty and sexual health education and training with men and boys, educators and school staff, parents/guardians, community-based workers (across sectors), and community and faith leaders that align with and support the education provided by schools, community health workers, and other channels creates gender-supportive environments for MH management and FP use.^20–22

2. Integrate Delivery of FP and MH Commodities and Services Within Health Systems

FP and MH can be deliberately integrated by providing services at the same delivery point and by offering referrals (Table 2). This should be grounded in the separate and growing evidence bases that exist for providing FP^23,24 and MH^14,25 commodities and services and should apply insights from the other areas of health systems integration (HIV-FP and FP-immunization) described earlier. This could include providing all or some of the following under a single program umbrella: MH information, FP counseling, menstrual product provision, FP method provision, and care for menstrual disorders. This level of integration could potentially enhance points of engagement with target groups across the reproductive life course, including often-ignored populations (i.e., perimenopausal women and out-of-school youth), resulting in enhanced service provision and improved SRHR outcomes. It also has the potential to increase cost-effectiveness with the improved efficiency of same-day, co-located service provision. One example of integrated delivery is the CHIEDZA program in Zimbabwe,²⁶ which provided menstrual products and FP counseling as a part of a broader package of SRH services. This study found that integration acted as a facilitator to engagement with SRH services overall.²⁶ Training and capacity-strengthening with health care providers and anyone else responsible for the delivery of FP and MH services is also important to ensure quality of care.^27,28 This could include training on integrated counseling approaches, as we describe in the next area of integration.

3. Improve Integrated FP-MH Counseling

FP counseling is an important entry point for providing MH information, including information on the menstrual cycle, menstrual product availability, pain management, and diagnosis and treatment of menstrual disorders. This should include referrals to outside services (Table 2) as well as a focus on self-care, which can enhance reproductive health outcomes.^29,30 Providing this basic MH information is also important in addressing the issue of contraceptive-induced menstrual changes (CIMCs). Evidence indicates that CIMCs frequently contribute to discontinuation and nonuse of contraception.^3,31,32 In addition, preliminary evidence suggests that high-quality counseling on CIMCs, including information about noncontraceptive health benefits, can help users make well-informed decisions about the specific method(s) that best meets their needs.³³ The “NORMAL” job aid, published in 2019, uses a simple mnemonic to counsel users to understand CIMCs, including potential health benefits and lifestyle advantages.^34,35 Beyond information provided by tools such as NORMAL, FP counseling should also provide information on the management of CIMCs. In addition, education and conversations about MH and the menstrual cycle, as described in Table 1, are important to ensure that individuals are ready for these counseling conversations later in life. Table 3 provides more details on this area of integration.

4. Include Evidence-Based Methods That Rely on Menstrual Tracking in FP Method Provision

Fertility awareness-based methods (FABMs) and the lactation amenorrhea method are important FP options, especially for those who prefer nonhormonal approaches and for people seeking postpartum FP, respectively.^36,37 FABMs include calendar-based methods that rely on tracking menstrual cycle dates as well as methods that, in addition to menstrual cycle tracking, rely on fertility biomarkers, including cervical mucus, basal body temperature, and metabolites of estradiol and luteinizing hormone in the urine.³⁸ Some FABMs are more effective than others, and there are a number of resources and job aids available for these.^36,38 An essential aspect of most FABMs is that users learn about their menstrual cycles more comprehensively during counseling as compared to other FP methods. This is because all FABM methods rely on ensuring a couple's understanding of and ability to track the menstrual cycle and identify fertile days. All FABMs are based on partner cooperation and familiarity with the concepts of menstruation and biomarkers of fertility.³⁹ The lactation amenorrhea method requires education about the impacts of breastfeeding on the menstrual cycle, which is also enhanced by an understanding of the menstrual cycle more broadly. Table 3 provides more details on this area of integration.

5. Address the Issue of Menstrual Status as a Barrier to FP

Providers often rely on the presence of menses as an indicator that someone is not pregnant before providing contraceptive methods; this can create a barrier if someone comes to the clinic on a day they are not menstruating.⁴⁰ In response, a pregnancy checklist tool was developed to address this issue.⁴¹ It is a job aid with simple questions that a provider can ask a client to rule out pregnancy based on criteria endorsed by the World Health Organization.⁴² Evaluations of the pregnancy checklist have demonstrated that the tool can be effective in ruling out pregnancy for more than 85% of people and use of the job aid can significantly reduce the proportion of clients being turned away due to menstrual status, thus improving access to same-day contraceptive services.^43–45 Research also shows that increasing the availability of simple, low-cost pregnancy tests^46,47 in FP programs can reduce barriers to FP access,⁴⁸ and a job aid is available to assist providers in deciding when to use the pregnancy checklist versus a pregnancy test.⁴⁴ In addition to these tools, education about the menstrual cycle among both providers and clients could be beneficial in addressing this issue. Table 3 provides more details on this area of integration.

6. Include Contraceptives as an Option for Managing Menstrual Disorders and Pain

While not usually a stand-alone treatment, contraceptives can be an important option for those managing menstrual pain and disorders like endometriosis and polycystic ovarian syndrome.^49,50 Health care providers should receive information about these options in their training, including being made aware that contraceptives are only a single part of a comprehensive care plan for menstrual disorders. In addition, those managing programs that provide MH education should include this information during educational sessions and integrate referrals to FP providers who have expertise in the management of these disorders. Table 3 and Table 4 provide more details on this area of integration.

7. Implement Social and Behavior Change Communication and Advocacy Programs for Stakeholder Engagement

Stakeholder engagement and education are essential to the success of any SRHR program, including for both FP and MH, to create supportive environments at all socio-ecological levels (Table 5). This type of stakeholder engagement can include providing education and information through social and behavior change communication (SBCC) and advocacy among politicians and policymakers.^14,51–53 These types of SBCC and advocacy interventions are essential for building awareness and demand for FP-MH services. Table 5 provides more details on implementing SBCC and advocacy programs.

8. Strengthen National Policies and Guidelines

Supportive policies and productive collaborations with ministries of health, water and sanitation, gender, and/or education will lead to more successful integrated FP-MH programs. This is because effective policies create enabling environments, remove barriers, and can lead to resource mobilization, all of which improve access and programs.^54,55 Several organizations working in SRHR globally have developed technical guidance on the integration of MH into SRHR (including FP) that can be used to inform future policies and guidelines.^56–58 Such global guidance documents are important for collaboration with global actors such as the World Health Organization and United Nations Population Fund and to ensure consistency across policies and guidelines. Table 5 provides additional details on strengthening national policies and guidelines.

Programmatic Guidance for FP-MH Integration

Stakeholders—including governments, donors, program managers, and health care providers—can facilitate stronger linkages between FP and MH through integrated models. The table in the Supplement combines all the evidence-based approaches in Tables 1–5 and is meant to guide stakeholders through the process of designing these integrated approaches on many different levels and for individuals across their reproductive life course. As stakeholders begin to design interventions, they should first determine in which areas of integration they will be working (i.e., education, SBCC, service delivery at the client level, etc.) and then determine the population they hope to reach. Suggested activities are provided where these 2 categories intersect. Stakeholders are encouraged to be comprehensive and reach populations with special needs whenever possible.