In this episode, we will focus on integrating family planning services with other health areas and settings. Featuring guests from Tanzania, Nigeria, and Bangladesh, we will examine specific actions that programs can take to involve communities and meet family planning needs. From HIV to maternal health to refugee camps, this episode will examine what elements of these integrated programs can be replicated in other settings to improve access to family planning.
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Sarah Harlan From Knowledge SUCCESS and the World Health Organization’s IBP Network, this is Season 2 of Inside the FP Story—a podcast with family planning professionals, for family planning professionals.
The international family planning field has generated a lot of data, a lot of reports, and a lot of lessons learned. But we don’t often have the opportunity to get behind that information, to hear directly from the people who implemented a program, or who did the analysis, and so we reinvent the wheel or miss the mark because we don’t know what could be really critical in a particular context. Inside the FP Story is that opportunity.
Each season, we hear directly from program implementers and decision makers from around the world on issues that matter to family planning programs. Through these honest conversations, we learn how we can improve our family planning programs as we work together to build a better future for all.
I’m Sarah Harlan, the Partnerships Team Lead for the Knowledge SUCCESS project. I’m pleased to welcome our narrator, Sakshi Sharma.
Narrator This season on Inside the FP Story, we’re partnering with the IBP Network to explore issues around implementing family planning programs. On our last episode—which was the first episode of this new season—we heard about programs that focus on community engagement to reach those living in rural and remote areas. Guests from Vietnam and Guatemala spoke about meeting the needs of women and their families by traveling to their clients’ communities, speaking their own language, and ensuring that they have access to a range of contraceptive methods.
As we heard in Episode 1, involving communities in activities and decisions that shape their reproductive health can have a multitude of benefits. Not only can it improve women’s knowledge of family planning and their ability to make decisions related to contraception, it can actually lead to higher levels of contraceptive use.
In this episode, we will continue the theme of community engagement—but will focus on integrating family planning services with other health areas and settings. Featuring guests from Tanzania, Nigeria, and Bangladesh, we will examine specific actions that programs can take to involve communities and meet family planning needs. From HIV to maternal health to refugee camps, today’s episode will examine what elements of these integrated programs can be replicated in other settings to improve access to family planning.
Our first story in this episode comes to us from Southern Tanzania, where EngenderHealth, alongside an array of international and national partners, created a one-stop shop for family planning services through an integrated approach. The program integrated family planning into HIV and tuberculosis screening days, immunization services, and HIV care and treatment facilities. The program increased family planning access and use—while also improving screening for HIV and tuberculosis.
To learn about this program, we spoke with Anna Temba, a Senior Technical Advisor for Family Planning and Reproductive Health at EngenderHealth. She works with the USAID Boresha Afya Southern program. She started out by explaining the basics of their “one stop shop” program.
Anna Temba So this is Anna Temba. I'm a senior technical advisor for family planning and reproductive health at EngenderHealth and working with USAID Boresha Afya Southern Zone program.
Narrator The USAID Boresha Afya Southern program provides integrated services at public health facilities, by government health care workers including family planning, HIV testing and services, TB screening and Gender based violence screening among others.
Anna Temba So the role of the program is to support them technically and financially to be able to provide the service. So when you talk about facilities, we talk about, you know, various levels from hospitals self-centers to dispensaries, but we also have, HIV care and treatment centers. Where in the HIV care and treatment centers, we provide integrated family planning and cervical cancer services. Generally in the facilities we’d be providing family planning services, and then we would integrate with other services like HIV screening and TB screening. But we also have community-based outreaches, so those now are not done at the facility they're being done at the community. And also family planning and immunization outreach.
Narrator Anna described what they call “family planning weeks”—where a team of health care workers stay in a community for five days to mobilize clients and provide a range of family planning methods, including permanent methods. They also advertise the integrated services in the communities.
Anna Temba So for integrated outreach, Because this is huge outreach, we have a big investment. The team is big. We provide a wide variety of services. We also invest heavily on client sensitization. We do public announcements using the PAs, but we also do community health workers doing home visits to sensitize clients, to come to the facility for family planning service.
Narrator Mobilizing family planning clients in this way allows these programs to reach more clients with a wide variety of methods, including long-acting and permanent methods like implants and intrauterine devices (more commonly known as IUDs)—while they also address other needs like HIV or TB care and treatment.
The program also makes an impact on the health care workers—allowing them opportunities to practice their skills thus contributing to a stronger health care system.
Anna Temba Like if you look at the numbers of family planning, trained providers in our country, it’s very high. Like almost every facility has had training at one point in time. However, they don't always provide the service, you know, that's because they have not received enough exposure to give them the competency, the desired competency. So when we go for outreach, there are so many clients who come in and in that way, the providers have room to do a bit more practice.
Narrator Anna talked about some of the challenges related to working on an integrated program—but also the benefit of combining efforts and avoiding multiple providers and parallel systems.
Anna Temba Everyone talks about integration as if it's a simple thing to do. However, when it comes to implementation, it's not very easy. For example, for our program, with HIV and TB and family planning. All these are vertical programs at the ministry of health. Like every component has its own section or department at the ministry, so they are actually not integrated. So when it comes to implementation, we also faced the same challenge. You know, everyone wants to run things parallel. So initially that was our challenge, you know, for the providers to be able to provide integrated services first based on their knowledge and competency, but also on their willingness to know it, you know, some would also think it's an additional work, right? “Why should I, you know, do all that?” So I feel like that was one of our biggest challenges, but we also were able to overcome it by showing, you know, we have various policies that are in support of integration. So we showed them that, you know, this is part of the national policy. It's nothing new. It's not like it's a donor driven approach. This is a government priority.
Narrator We asked Anna what she hopes people learn from their implementation experience.
Anna Temba First, I would hope they learn about the effectiveness of integration. Because I feel like it's just the way to go. It helps the client receive so many services at par, which are all important. and it helps the providers to also, you know, minimize time and workload. Because a service that should have been provided by two or three providers is now being provided by one provider, you know, in one setting. You're saving the client's time, we're saving the providers time, and we're also saving the resources that would be used to provide all the services. So, if there is anything I would like, you know, people to learn is that integration is effective. However, it requires commitment and leadership. And that should be at the core of the design. You just cannot do it at the end.
Narrator In order for integrated programs to be successful, it is important for countries to have supportive policies and data collection tools to support integrated services—as well as financial and technical capacity in order to provide multiple services to clients under one roof. It’s also important that programs are able to ensure that activities are actually being integrated, and that supportive mentorship is provided for fidelity and sustainability of integrated programs.
Narrator Now we will hear about a program on the other side of the African continent—focusing on integrating family planning with postpartum care—with a particular focus on long-acting reversible contraceptives. In Nigeria, the Clinton Health Access Initiative, in collaboration with the Nigerian Ministry of Health and state governments, implemented an approach that ensured that women received voluntary postpartum family planning information at all points of care.
We spoke with Olufunke Fasawe of the Clinton Health Access Initiative—also known as CHAI.
Olufunke Fasawe My name is Olufunke Fasawe and I work with the Clinton Health Access Initiative based in Nigeria. I am a Senior Director for our global primary health care strategy, and I'm also the Director of Programs for the Nigeria office, where I lead our sexual reproductive maternal newborn work as well.
Between 2016 and 2019, CHAI supported three governments in Northern Nigeria—Kano State, Kaduna State, and Katsina States, which are located in the Northwestern region—to implement a program that integrated postpartum family planning into the broader maternal and newborn health continuum of care.
What we did in those three years really was to work with the three state governments to come up with an approach that saw to implementing postpartum family planning as part of the maternal newborn health continuum.
We weren't just focused on the immediate postpartum period, which is 10 minutes to 48 hours post-birth, but we also looked at up to six weeks post delivery. In the end, it was really just about making sure that these women had information at every point of contact within the health facility, whether it was antenatal, whether it was immunization, whether it was postnatal clinics, women had to know about their options.
Narrator Olufunke went on to explain the three key objectives of the program.
Olufunke Fasawe So, the three key objectives of the program were—one, increasing access points for high quality postpartum family planning services. The second was strengthening the capacity of healthcare providers through clinical training and clinical mentorship to be able to adequately, and without bias, provide these services to all women who needed them and wanted them. And the third was community involvement. How do you leverage the role of community influencers to be able to adequately inform women, particularly those women who do not come back to the facility to deliver. And within that also was to work with communities to strengthen referral services so that where women are adequately informed they are also able to go to the facility within 48 hours post delivery to access the services.
Narrator By the end of the program in June 2019, they were able to reach over 146,000 women in these three states, who received postpartum IUDs or implants within 48 hours after delivery. This was a significant achievement—because they went from having almost no postpartum family planning available in those three states, to 30% of women receiving IUDs or implants after delivery. And not all the women who received these services even delivered their babies in a health facility—25% of them delivered at home and were referred for the family planning service.
Part of what made the program successful was engaging community leaders.
Olufunke Fasawe So the very first thing we did was targeting traditional leaders, religious leaders, and empowering them with the right information, helping them to understand the benefits of women accessing family planning services, but more importantly, recognizing that it wasn't about planning families, right? It's about healthy timing and spacing of births. And so that was something we spent a lot of time on helping to understand how healthy timing and spacing of childbirth reduces maternal mortality, which they could all relate with because they've all seen it many times - mothers, sisters, daughters that have died as a result of pregnancy related causes.
Narrator As we have heard in some of our other stories this season, getting the buy-in of gatekeepers in communities is often critical for family planning programs. In the case of the CHAI program, one group of gatekeepers they identified were traditional birth attendants—or TBAs.
Olufunke Fasawe Because of some of the gender related issues in Northern Nigeria, you have a situation where, a lot of women would not allow male providers for example, to assist them during birth. So you have a situation where a majority of women are delivering at home because of cultural reasons. And the first point of contact in many cases is a traditional birth attendant or someone in the community that is recognized as experienced and has delivered or assisted a lot of deliveries.
So we identified these traditional birth attendants and we worked very closely with them, over 2,800 of them to improve their own knowledge and understanding of family planning, postpartum family planning, the benefits and how that in itself empowers more women to make informed choices.
Narrator Strengthened referrals was another key aspect of CHAI’s community engagement strategy, to make sure that women who opted to have immediate postpartum family planning could access this service. They also worked with community leaders and healthcare workers to ensure that motorbike ambulances were available.
Olufunke Fasawe So if a woman had had a baby and within 48 hours she wanted to go for immediate postpartum IUD, she was able to utilize the motorbike ambulance to get to the facility. And that was super, super huge for the program because by the end of the project, we saw that of all the women who came to receive an immediate postpartum family planning, whether they delivered at the facility or they delivered at home, we saw up to 30% of those women who were receiving an immediate postpartum family planning method within 48 hours. Up to 30% of those women were actually women who had delivered outside of the health facility and came to the health facility to receive the service.
Narrator Although this program was very successful, it took some time to get it right. Olufunke explained that the program learned a valuable lesson—supply and demand issues go hand-in-hand, and community engagement is key for increasing demand.
Olufunke Fasawe And so we implemented, we started to engage very closely with the traditional birth attendants. We had what we call champion TBAs. So, champion TBAs were like these TBAs who are super passionate, who went all out to identify a lot of the women delivering outside of facility. You know, sensitize them, counsel them, refer them. So in each local ward, we try to identify one champion TBA and that approach completely changed. We saw a four fold increase in the number of women who started to access postpartum family planning within a year of implementing that approach. And it just continued to grow from there, you know? So, I think having the community piece is critical.
Narrator Working with TBAs, the program was able to ensure that healthcare providers were counseling women well, and providing rights-based family planning services without judgement.
So training was one key aspect. Another was identifying the key services to integrate with family planning. Through conversations with the heads of health facilities, program staff realized that family planning wasn’t necessarily included in antenatal health visits. So they saw this as an opportunity. They also saw immunization visits as an opportunity for integration.
The program team worked with ministries of health, healthcare workers, and primary health care agencies, to improve the clinic workflow. Along with providing high-quality family planning services and increasing community referrals, reorganizing the clinic workflow was key to the success of this program.
Olufunke Fasawe We also clearly identified that in the maternity unit, there were a few things that needed to happen. One was active counseling on postpartum family planning, having data tools so that when women receive the service, it’s recorded. But more importantly, is having commodities in the maternity units because we saw a huge gap in, if you had to say, okay, a woman has just delivered and she needs an IUD… are you then going to, you know, refer this woman, have her get up 10 minutes after delivery and walk another five minutes across the facility, just because she wants to get an IUD? And so we worked again with the facilities to ensure that commodities were available in the maternity units and data tools were available, which could then, you know, track how many women are being served.
Narrator When we asked about their biggest challenge, Olufunke described the difficulties ensuring sustainability of commodities.
Olufunke Fasawe We worked very closely with the ministries of health in each state to use data to be able to track consumption patterns and to use that, to inform the distribution of available commodities to the last mile.
Narrator The program was also able to leverage their relationship with the federal ministry of health to alert them when facilities were running out of stock—this has helped prevent stock-outs, but commodity shortages remained a challenge. In general, Olufunke said working with government structures is key to successful integration approaches.
When it comes to integration, there are so many services that can be combined with family planning. We asked Olufunke why integrating family planning with maternal health care is so important.
Olufunke Fasawe The data clearly shows that the more women are able to plan pregnancies, the better maternal outcomes you have, but also the better impact you have on children's development. Right? So, I think family planning is a no brainer and is a low hanging fruit, if we want to really address some of the factors that drive poverty and poor outcomes in many societies.
Postpartum family planning is even more important because usually when you just had a baby, You know, your immediate thought as a woman is how am I going to give the best to my baby?
I see postpartum family planning as an empowerment for a lot of women, because, they're able to really take charge of that period after birth.
Narrator Integrating with maternal health services is also more cost-effective from the perspective of the health facility. But beyond that, integration allows us to focus on the client more holistically.
Olufunke Fasawe I think it's really important that we start to center care on the women, on the clients, on the patients, and design service delivery to meet patient's needs.
Narrator In providing high quality postpartum family planning services, increasing community referrals through traditional birth attendants, and reorganizing the clinic workflow so that pregnant women received voluntary postpartum family planning information at all points of care—this program led to over 146,000 women choosing and receiving voluntary FP immediately after delivery, 25% of whom delivered at home and were referred.
And although this CHAI program ended in 2019, the postpartum integration has been sustained.
Narrator So far this episode, we have focused on the integration of family planning with other health areas—HIV, TB, and postpartum family planning. However, it is also important to consider ways that family planning can be integrated into other community programs—this is particularly important in humanitarian settings, where the existing healthcare structure may be limited.
In Bangladesh, the International Rescue Committee works in partnership with UNFPA and MUKTI Cox’s Bazar, to lead discussion groups among men in Rohingya refugee camps. During the discussion sessions, approximately 40 men discuss voluntary family planning and the importance of male engagement in reproductive health. This program was implemented in 19 camps that had women-friendly spaces.
We spoke with Shamiya Nazir, formerly of the International Rescue Committee, about this program and its importance.
Shamiya Nazir I’m Shamiya Nazir I used to work as the sexual reproductive health manager for international rescue committee. And I was based in Cox's Bazar, Bangladesh.
Why we choose this is because of the social circumstances, power imbalance between men and women.
And. Also, the child marriage rate is decreasing in Bangladesh, but we see from Rohingya community that, they're still practicing that. They are still having more than four or five kids in general. The starting marriage for the girl is really low. Like 12, 13, they start getting married and married to a very older guy.
Narrator In addition to high fertility rates and child marriage, Rohingya refugees also face high rates of gender-based violence, often at the hands of their partners.
Shamiya explained that engaging men within Rohingya households is especially important given they are typically the primary decision maker for all matters related to the health and well-being of the family. So how did the program introduce the topic of family planning among men?
Shamiya Nazir I started talking about it and it was a very casual conversation. It was not like I'm trying to give information, medical terms. It's not like that. So first, I asked what is the issue with family planning? Like, why they don't like it? The one thing that came out through their conversation, even I heard from before is that, they lost a very good amount of lives due to their civil war. And there was a kind of emotions that they want to make a recovery, you know? And then also having the idea that that was their part of culture, right?
Narrator Men in the camps considered high fertility rates to be central to their culture—and also considered this replacement for Rohingya lives lost to war. However, over time, and after the group discussions with the program, their attitudes towards family planning began to change.
Shamiya Nazir I didn't talk much. I just initiated the dialogue and let them talk more and I just intervened from time to time. And then, what happened is that what doubts they have, they started coming out and they're getting clarified. And after that, after we ran through the session for a year, our midwife said, they don't get questions anymore when they going for outreach program. Because the men and community know what they’re doing. And then men started sending their women to get, in fact, long-term family planning methods.
That was a very, very big achievement.
Narrator Over a 10 month period, the program led to a six-fold increase in the number of new contraceptive users along with reductions in stigma and changes in attitudes about voluntary family planning among men in the camps. Shamiya emphasized the importance of being patient—and the importance of considering the cultural aspects that go into family planning decision-making.
Shamiya Nazir So, I think overall it had a good impact and it will have and it is having for the people who are from different cultural settings. Sometimes we have to have the patience. What happened like usually like health implementation experts try to run a program based on their experience based on what they have learned from their academic lives. But ignore the existing culture. This is the thing I wanted to highlight. Your program, your work, your everything, it's your clients. So whatever you do, you have to make sure they have to be benefited in their way. You cannot suddenly change everything.
Narrator In addition to facilitating and letting the men talk among themselves, the program team also worked with male leaders in the camp and integrated with some other sessions, using their venue after they finished with other community meetings.
Meanwhile, the women in the camps often congregate at “Women Friendly Centers”—or WFCs. WFCs create a casual environment for women to meet, relax, and speak with trained professionals regarding family planning, mental health or other topics. Many women prefer going to a WFC instead of a health center and feel more free discussing sensitive topics at WFCs. They can also meet with case workers and midwives to get health information and referrals—including those for family planning.
We asked Shimaya about the benefits of integrated services among the Rohingya community.
Shamiya Nazir So you see like, In one place you can offer a lot and that's, this is the way one program can integrate with another program. And then, it can also help with saving money too. Otherwise you'll have one center there, one center there, and it takes space as well.
Narrator In Rohingya culture, men are the primary decision-makers in the family. Involving them in the program was crucial for promoting the use of voluntary family planning.
Shamiya Nazir And for us, it has to be something they will like, and they agree, and they will see benefit. So, that's why when we started talking to them about family planning, we talked about a unit, not only female. We talked how as a family unit can be benefited by that. And considering their emotions and also cultural practice.
Narrator At first, there was also resistance among men in the community because the programs were led by women.
Eventually, the program hired male staff, which helped the men in the program feel more comfortable in the conversations. These discussions, facilitated by the International Rescue Committee, encouraged the men to discuss these issues and they eventually came to the conclusion that having fewer children may benefit their families—these men had not generally been involved in these discussions before, and this program motivated them to discuss contraception—starting with health providers, peers, and community leaders.
Shamiya Nazir Usually family planning professionals or service providers tend to talk to only women, but here, when they heard them included, they feel empowered, like they feel like they are part of the family too, that their decisions is important, which is already in like, in their family, but they thought like their decisions is important to us too.
Narrator Shamiya also mentioned including religious leaders in their community engagement activities. For one thing, Muslim leaders in the Rohingya community opposed long-term family planning methods like IUDs—placing foreign objects in the body is prohibited, and thought to cause infertility or other problems. To speak to these leaders about contraception, Shamiya and her team first sought to understand this cultural context so they could address their concerns about family planning. They described the contraceptive devices as medical items, and answered their questions. This was crucial to acceptance of family planning among the Rohingya, given that the opinions of religious leaders are highly respected in the communities—and any information they shared about family planning, whether positive or negative, spread quickly throughout the community.
We also asked Shamiya how these programs may be able to not just accommodate existing gender dynamics, but actually push for more gender transformative family planning programs—those which empower women as decision-makers.
Shamiya Nazir We tried to empower women in Rohingya settings. We try to make them aware that it's your body and making it healthy and keeping it healthy, it's your right.
We are there not to initiate any cultural conflict. We are there to help. Every change takes time. So, mentally we have to be prepared.
Narrator When we asked her if she thought this type of program could work in other settings, she said it could, but it needs to be customized based on the existing culture, and it is important to consider how male engagement programs will affect women as well.
Narrator All three of these stories show the importance of engaging communities when integrating family planning with other health areas and settings. While these stories come from three very different locations, they all show the importance of understanding the cultural context, involving community leaders, and leveraging existing systems and networks to provide voluntary family planning services.
These stories are part of a series of 15 stories selected from a global competition hosted by IBP and Knowledge SUCCESS to highlight experiences implementing High Impact Practices and WHO guidelines. If this episode left you hungry for more, we encourage you to read the other stories on the IBP Network website and join us for episode 3 where we'll dive into strategies for working with and for adolescents and youth.
Inside the FP Story is a podcast produced by the Knowledge SUCCESS project and the World Health Organization’s IBP Network. This episode was written by Sarah Harlan and Anne Ballard Sara, and edited and mixed by Elizabeth Tully. It was supported by an additional team, including Nandita Thatte, Ados May, and Carolin Ekman.
Special thanks to our guests Anna Temba, Olufunke Fasawe, and Shamiya Nazir.
To download episodes and to find additional links and materials, please subscribe to Inside the FP Story on Apple Podcasts, Spotify, or Stitcher. You can also find Spanish and French transcripts at KnowledgeSuccess.org.
The opinions in this podcast do not necessarily reflect the views of USAID or the United States Government.
If you have any questions or suggestions for future episodes, feel free to reach out to us at info@knowledgesuccess.org.
Thank you for listening.