Integrating Family Planning and Menstrual Health in Policies and Programs
On November 16, 2023 Knowledge SUCCESS, in collaboration with the Contraceptive-Induced Menstrual Changes Community of Practice, hosted a webinar that highlighted the linkages between the fields of family planning and menstrual health and took participants through recently published programmatic guidelines for family planning-menstrual health integration.
A recording of this event is available in both English and French, and the presentation slides are available for download here.
Family planning and menstrual health are closely related fields that are often not effectively integrated, which can result in missed opportunities to improve the health, well-being, and dignity of individuals. Integrating family planning and menstrual health could help address challenges of stigma, misinformation, and navigating complex social and gender norms and increase the reach and impact of both fields. Recent work has brought together experts from the two fields. In breaking down silos, a growing interest in this topic of integration has emerged and experts agree that greater efforts should be made to proactively link family planning and menstrual health policies and programs including through provider training and capacity strengthening, community and school-based education and outreach, service provision, and program evaluation.
This event aimed to highlight the linkages between these two fields and offer practical guidance for integration. The webinar was moderated by Irene Alenga of Knowledge SUCCESS. It began with a discussion between Tanya Mahajan, menstrual health expert and Director at the Pad Project, and Dr. Marsden Solomon, an independent consultant and family planning expert, which highlighted the connections between the fields of family planning and menstrual health. Emily Hoppes of FHI 360 then took participants through recently published programmatic guidelines for family planning-menstrual health integration. All three presenters participated in a question-and-answer session and the event concluded with a group brainstorming activity.
A Conversation between Family Planning and Menstrual Health
This conversation began with panelists, Tanya and Dr. Solomon, reflecting on the key tenants of their respective fields. Dr. Solomon emphasized family planning’s roots in voluntarism and human rights, explaining that clients must be provided with everything they need to make an informed choice about the method that best fits their lives and that individuals or couples should make decisions about the number of children and timing of pregnancies for themselves without coercion from providers or anyone else. He also mentioned the multisectoral nature of the field of family planning and its connections to education and environment, among others. Tanya explained that the field of menstrual health is similar in its basis in human rights and multisectoral nature. She also described how menstrual health has been shaped by feminist approaches and by the voices of menstruators themselves. Tanya also emphasized the importance of advocating for body literacy across all aspects of menstrual health. A final aspect mentioned by Tanya was the importance of engaging a wide range of stakeholders, a concept that is also important to family planning.
The panelists were then asked to reflect on how their respective fields could learn from one another and benefit from integration. Dr. Solomon mentioned two key areas where the fields overlap during family planning practice: 1) when couples are being counseled through the use of fertility-based awareness methods, like the Standard Days Method, they are provided with education about how the menstrual cycle works and is related to fertility, and 2) in discussing contraceptive side-effects, clients should be educated about contraceptive-induced menstrual changes with a job aid like the NORMAL tool, to address these common concerns. Tanya agreed with Dr. Solomon and mentioned that menstrual health education and an understanding of the biology of menstruation is a key step in supporting the connections he discussed. She also emphasized the role of menstrual health in engaging people in conversations about reproductive health early in their reproductive life cycle, as well as later, as their reproductive years are ending. 
Tanya then reflected on how the field of menstrual health can learn from the field of family planning when it comes to offering full, free, and informed choice.
The conversation concluded with both Tanya and Dr. Solomon expressing their excitement about the potential for family planning-menstrual health integration to improve the of health people across the life course and the opportunity it provides to increase program effectiveness and reach.
A summary of the key concepts discussed in this panel are provided in the Ven diagram shown above.
Programmatic Guidance for Strengthening Integrated Approaches
In the second part of the webinar Emily Hoppes of FHI 360 presented a summary of the programmatic guidelines for family planning-menstrual health integration that were published in Global Health Science and Practice in October. She began by explaining how the guidelines are informed by and organized according to the socio-ecological model and life course approach. Emily then took participants through five examples of suggested activities and methods for integration:
- Including evidence-based puberty and comprehensive sexuality education for youth/adolescents that includes age-appropriate information on menstruation and fertility, managing menstrual bleeding and pain, menstrual health, and family planning.
- Providing affordable, high-quality menstrual health products, facilities, including clean, private toilets with space for washing and disposal, and other resources to family planning clients during counseling.
- Providing effective, evidence-based counseling during and after method selection about potential contraceptive-induced menstrual changes.
- Ensuring all individuals with menstrual discomfort and/or disorders have adequate counseling and access to contraception as a management or prevention option.
- Reviewing and updating family planning, menstrual health, and sexual and reproductive health and rights guidelines to ensure they include adequate, evidence-based information about family planning-menstrual health integration.
The presentation was concluded with a call for more research on this topic in order to better understand which models of family planning-menstrual health integration are most effective and have the largest impact.
Participant Questions
LIVE Q&A
Question 1: In the context of menstrual health, what message should be conveyed to women who complain of (express concern about) not menstruating when using DMPA, despite having been warned of this possibility during counseling?
Dr. Solomon: It is very common for DMPA (injectable contraceptives) to cause a pause in bleeding, which is referred to as amenorrhea, and this can cause a lot of anxiety in clients. This is because clients are used to having a monthly period and they wonder where the blood is going if it is not being released during menstruation. Providers need to be prepared to counsel and reassure clients that this is a completely normal effect of the method and that it is not harmful to their health.
Question 2: Do you have a list of research questions you can share? And are there any ongoing research opportunities you can share?
Emily Hoppes: A lot of the work being done on this topic to-date has been focused on the issue of contraceptive-induced menstrual changes (CIMCs). The CIMC Research and Learning Agenda provides a list of research questions related to this topic specifically, as well as a few others related to family planning-menstrual health integration more broadly. There is also an opportunity to get involved in this work through the CIMC Community of Practice. Overall, there is a need for more research and funding.
Question 3: Listening to this discussion justifies integration of contraception and MH services. However, there is resistance from several stakeholders in Uganda regarding extending contraception to adolescents. Are there targeted messages for such groups (e.g., religious leaders, and some parents) to help them appreciate this?
Tanya Mahajan: There is a need to use (and gather more) data showing the unmet need for contraception amongst adolescents in Uganda and globally.
Emily Hoppes: Education and programs should be age-appropriate and tailored to the group that is being targeted.
Question 4: How do health workers counsel women of childbearing age on the choice of family planning methods with various methods available without missing out the benefits?
Emily Hoppes: Family planning counseling should provide complete information about all methods available, including information about both the potential side effects and benefits of each of these methods and finding which product profile fits best within that person’s life. This includes providing information about side effects related to menstruation, for example an increase in bleeding or pain, as well as “side benefits” related to menstruation, for example reducing pain or helping to manage menstrual disorders like endometriosis.
Tanya Mahajan: There is a related situation that happens in the menstrual health world where providers often pushing products that are more readily available or emphasize the negatives of products that are unavailable due to supply chain issues. It is important that supply chains are developed so that providers area able to offer choice among a full range of products.
Question 5: Are there examples of countries that provide menstrual health commodities at family planning clinics for clients? If, yes, are these menstrual health commodities provided for free or at a price?
Tanya Mahajan: There have been some social marketing organizations and clinics stocking mostly disposable menstrual pads, usually at a subsidized price, but choice amongst a wide range of products is not usually made available.
Emily Hoppes: There are not a lot of great examples of this. Often this happens in humanitarian contexts where a packaged of SRH products are provided, which includes both family planning and menstrual health products. This is an area where we really need to implement and research programs to better understand how it might work.
Tanya Mahajan (in the chat): Here is another resource for integrating a basket of menstrual products in humanitarian settings.
Question 6: Speaking of funders, could you share which ones are those interested in the area of FP/RH integration? (programming and/or research wise)
Emily Hoppes: Funding sources are currently very siloed – some provide funding for family planning work while others provide funding for menstrual health, but they are rarely funded together. USAID funded the development of the FP-MH integration guidelines and currently funds the work of the CIMC Community of Practice. The Bill & Melinda Gates Foundation is also funding research related to CIMCs. We need to continue to talk about this topic and draw attention to it in order to attract more funders.
Q&A FROM THE CHAT
Question 1: In low resource countries where access menstrual health commodities are limited due to high cost, how can this integration be achieved?
Dr. Solomon: Irregular periods are a common characteristic of the perimenopausal period (the stage at which one is approaching menopause). This stage is also associated with chances of conceiving (though the percentages can be as low as 2 %). If a client does not wish to conceive, they should be advised to use a family planning method. Perimenopausal women can use any method, subject to Medical Eligibility Criteria.
Questions 2: How can we advise women approaching menopause who have very irregular periods on FP?
Dr. Solomon: Irregular periods are a common characteristic of the perimenopausal period (the stage at which one is approaching menopause). This stage is also associated with chances of conceiving (though the percentages can be as low as 2 %). If a client does not wish to conceive, they should be advised to use a family planning method. Perimenopausal women can use any method, subject to Medical Eligibility Criteria.
Emily Hoppes: In-line with the programmatic guidance, providers should also ensure that perimenopausal people have access to low-dose contraceptives as an option to relieve menopause symptoms.
Group Brainstorming Activity
In order to gather feedback and ideas for developing a more user-friendly version of the programmatic guidelines for family planning-menstrual health integration, webinar participants were encouraged to share their thoughts around a few key questions.
How might you be able to integrate family planning and menstrual health and put these guidelines into action in your current work?
This question generated a number of interesting and exciting ideas, with examples across many countries, including Ethiopia, Ghana, Madagascar, Malawi, Nigeria, The Netherlands, and Uganda, including the following:
- Integrating menstrual health and family planning supplies at various levels across the supply chain.
- Using the guidelines to work with youth and their parents.
- Integration in humanitarian settings.
- Developing a simple tool for menstrual cycle awareness to use during family planning counseling.
- Integration at the policy level.
- Generating more evidence to highlight the issue and need for family planning-menstrual health integration.
- Advocating for more investment in research and programs.
- Sharing these resources with colleagues working in family planning and menstrual health to raise awareness about the need for integration.
What would you suggest we do to make the guidelines more accessible, understandable, and user-friendly to both menstrual health and family planning practitioners?
Participants shared a number of useful ideas for improving this resource, including:
- Convert the guidelines to a digital format.
- Make them more visual with infographics and less technical.
- Include concrete examples and case studies.
- Translate into French and other languages.
- Involve the people who will be using these guidelines (program implementers, community health workers, policymakers) in in developing the user-friendly version.
- Share these guidelines in many different venues, including the WHO site and Training Resource Package for Family Planning.
A Call to Action
This webinar and the publication of the programmatic guidance for family planning- menstrual health integration is an incredible start to what will hopefully be a growing area of work globally. The integration of family planning and menstrual health has the potential to address stigma and misinformation, while improving the health, well-being, and dignity of individuals, and optimizing the impact of both fields. If you are interested in using these guidelines to inform future work, please reach out to Emily Hoppes (ehoppes@fhi360.org).
Additional Resources
