Family Planning Integration
What Is It?
Offering family planning counseling, referral and/or services to a woman when she visits a health facility for another reason, such as antenatal care (ANC), immunization, sick/well baby clinics, curative care for children’s illnesses, post-abortion care, or HIV/AIDS voluntary counseling and testing. Family planning counseling and services can also be offered in the labor ward, before a woman gives birth, and after delivery or postpartum. It incorporates aspects of two or more services as a single, coordinated combined service.
Integrated service provision can take place in the same room by the same provider or by a different provider in the same facility (usually in different clinics) or even in different facilities. When services are not offered in the same room, and especially if not in the same facility, strong referral systems are required.
What Are the Benefits?
- Offers a one-stop shop where clients can receive multiple services, increasing access and convenience by reducing the number of facility visits
- Maximizes available human resources at facilities; expands the number of providers who can offer family planning
- Takes advantage of women’s time and presence at the facility
- Creates an opportunity to introduce family planning to new clients
- Allows women who may be hindered by [simple_tooltip content='Family planning can be a sensitive topic in many countries. For example, in many states in Nigeria, family planning is referred to as child birth spacing because the phrase family planning carries many negative connotations']social norms[/simple_tooltip] to seek family planning under the cover of other curative services.
TCI has found the following points of integration to be the most impactful: family planning integration with childhood immunization visits, postpartum family planning, and post-abortion care. Each is considered its own high-impact practice (HIP). The below “How to Implement” guidance provides general considerations.
For more specific guidance related to each intervention, check out HIP briefs on Immediate Postpartum Family Planning (PPFP), Post-abortion Care (PAC) and Family Planning and Immunization.
Tips from Implementation Experiences
- Invest in good documentation and monitoring to help ensure voluntarism and informed choice.
- Consider home visits if targeting PPFP adoption among first-time, young parents.
- Offer the broadest range of contraceptive methods possible and make them available prior to maternity discharge.
- Consider leveraging antenatal care visits to educate clients on contraception.
- Do not forget men.
- Encourage facility leadership and adjust management practices based on facility size.
For more detailed country-level PPFP operational guidance, refer to TCI's experiences in Philippines, East Africa and Francophone West Africa.
- Address stigma and social and community barriers.
- Engage communities and community health workers.
- Engage support networks.
- Offer PAC at primary care facilities and allow nurses and midwives to provide care to expand access and reduce costs.
- Offer a wide range of contraceptive methods.
- Encourage and support providers to treat all clients respectfully.
- Make contraception free or bundle it with the cost of post-abortion treatment.
- Do not integrate family planning services into mass vaccination campaigns.
- Keep family planning messages simple and reinforce provider communication skills via training, job aids and on-site mentoring for vaccinators.
- Consider systematic screening.
- Establish straightforward referral systems that facilitate client access to family planning services.
- Ensure a clearly defined client flow to provide both services within a specified window of time.
- Monitor integration’s impact on both family planning and immunization services and outcomes.
How to Implement
Identify facilities as good candidates for integration activities
An assessment tool developed by the Nigerian Urban Reproductive Health Initiative (NURHI) can help you identify which facilities to target for integration activities. Using this tool, NURHI found that many potential family planning clients visited high-volume sites for antenatal care, childhood immunization services, labor and delivery, postabortion care, or HIV services, and so the project targeted these high-volume facilities for integration of family planning. The assessment may uncover different types of facilities that would make good choices for integration depending on the setting.
Facilities selected for integration should have some level of preparedness and readiness in terms of space availability, equipment, and staffing to deliver family planning services, information, and counseling in addition to the services they are already providing.
Select which services to integrate with family planning
Contraceptive uptake has increased when family planning services have been integrated with these other types of services:
Outpatient clinics
- ANC services
- Child welfare services (immunization, sick/well baby clinics)
- Postnatal services
- HIV services
- Curative services
Inpatient clinical services
- Labor wards
- Postnatal/postpartum wards
- Post-abortion care services
Determine the appropriate range of integration
Not all service delivery points are able to provide the full range of family planning services; some facilities may not have adequate infrastructure, equipment and supplies, or staffing. Linking and referring to existing family planning services (either within or outside the facility) is an alternative strategy that can still help clients obtain a wider range of services. Provider-initiated family planning is a specific strategy that can be used to improve integration of family planning into other health services. It involves screening all women who enter a health facility for their family planning needs, regardless of the reason they come to the facility. The same provider also counsels the women on their contraceptive options and provides the appropriate methods, if possible, or refers the women to a family planning clinic.
Integration is possible in every setting, but the level of integration depends on the context. Keep in mind that integration can be structural (creating space for family planning within another service) or functional (using what is already there). See below for information about the range of options for integrated services.
How Does Integration Look? A Range of Options
COUNSELING AND METHOD PROVISION
Providers can be trained to offer family planning counseling and provision of methods in addition to the service(s) they already provide (e.g., immunization).
COUNSELING ONLY
Providers offering other services can be trained to counsel women on family planning but refer interested clients to a family planning clinic for method provision.
SCREENING ONLY
Providers could identify women with unmet need for family planning (e.g., through a screening tool) and refer them to the family planning clinic for both counseling and method provision
Build the capacity of service providers
Service providers should be trained according to the country’s national guidelines on family planning integration, usually developed by the Ministry of Health. In many countries, specific guidelines exist for integrating family planning into HIV services and into maternal and child health services such as postpartum care and immunization services.
Design your training based on the needs of the providers and any gaps in skills. You can refer to the following templates and examples from other countries as a starting point and adapt them to your local context.
- Training PPT from Francophone West Africa
- Training PPT from East Africa
You can also train providers on integrated services in the context of skills updates. For example, if there is refresher training for providers every year, you can incorporate a module on family planning integration.
If planning to introduce provider-initiated family planning, you can use and adapt a slidedeck developed by the Tupange project in Kenya to train others on this approach. All Urban Reproductive Health Initiative countries used this job aid on provider-initiated family planning with great success.
Equip integration service areas
Identified integration service areas should be provided with relevant equipment, stationary, information, education, and communication (IEC) materials and job aids, commodities, and reporting tools. For example, providers working in the postpartum ward may need IEC materials on immediate postpartum IUD provision.
Develop, print and distribute referral slips as necessary
Strong referral systems between clinics in the same or other facilities can help clients adopt family planning. If it isn’t possible for one provider to offer multiple services, a client can be given a referral form when leaving one clinic (e.g., immunization) to take to the family planning clinic.
The form should signal to the family planning clinic providers – and workflows rearranged if necessary – that this client should be prioritized to reduce the time she spends waiting in line.
What Is the Evidence?
In Nigeria, active referrals for family planning from ANC clinics, childhood immunization services, labor and delivery, postabortion care, or HIV services resulted in substantial increases in women and HIV clients receiving family planning information.
In India, women who had received family planning counseling during their time of delivery at a health facility were more than twice as likely to use a method postpartum than those who had not received family planning counseling.
In Senegal, the number of new family planning clients served in the Nmzatt facility increased drastically after introduction of provider-initiated family planning, from less than 20 clients per month in the year prior to implementation to about 60 clients, on average, per month in the year after starting provider-initiated family planning.
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Helpful Tips
- New to integrating services? Start with a high-volume facility, and then phase family planning integration into smaller facilities.
- Encourage providers and facility managers to be flexible and work together. For example, adding family planning services to a noisy, busy immunization clinic may not be feasible—but giving women priority referrals to a nearby family planning clinic might be.
Challenges
- Lack of space or infrastructure may not provide adequate privacy for clients and/or make it feasible to add family planning services.
- Additional costs are likely to be associated with integration (for example, the need for extra staff, training, IEC materials, and reporting tools).
- Providers may experience increased workloads.
- Clients may experience increased waiting times.
- Counselors without clinical training may be intimidated to discuss contraceptive methods and how they work.
External Resources
- High Impact Practices in Family Planning (HIP) Brief on Postabortion Family Planning
- HIP Brief on Family Planning and Immunization Integration
- USAID Global Health Learning Center course on Postpartum FP
- USAID Global health Learning Center course on FP and HIV Service Integration
