Featuring interviews from guests who specialize in this topic, this episode will focus on both the physical and social aspects of menstrual health and discuss the importance of inclusive integration of family planning and menstrual health—including adolescents and young people, those living in humanitarian settings, and people of all gender identities and expressions who menstruate.
www.knowledgesuccess.org/inside-the-fp-story
From Knowledge SUCCESS and FHI 360, this is Season 6 of Inside the FP Story—a podcast developed with the family planning workforce, for the family planning workforce.
Each season, we hear directly from implementers and decision makers from around the world on issues that matter to our programs and services. 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 am Sarah Harlan, Partnerships Team Lead with the Knowledge SUCCESS project. I am pleased to introduce our narrator, Charlene Mangweni-Furusa.
Narrator: Welcome to Season 6 of Inside the FP Story. This season, we are moving beyond a narrow definition of “family planning” to explore the larger context of sexual and reproductive health (or SRH). In our previous episodes, we provided an introduction to SRH and discussed adolescent and youth SRH (or AYSRH), the integration of family planning and HIV, and the importance of addressing sexually-transmitted infections within family planning programs.
While some of those topics are well-researched, well-funded, and widely-discussed, this episode will introduce a topic that is just beginning to gain more attention: The integration of family planning and menstrual health. Featuring interviews from guests who specialize in this topic, this episode will focus on both the physical and social aspects of menstrual health and discuss the importance of inclusive integration of family planning and menstrual health—including adolescents and young people, those living in humanitarian settings, and people of all gender identities and expressions who menstruate.
Narrator: The following definition of menstrual health was developed by the Global Menstrual Collective, a group of diverse stakeholders that collaborate to drive and guide investment in menstrual health through evidence-based advocacy:
“Menstrual health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, in relation to the menstrual cycle.” This definition aligns with the World Health Organization’s overall definition of health—and includes mental and social well-being, as well as physical.
Overall, menstrual health integration with primary health care—including within maternal and child health and SRH services—is limited. But what does it mean to better integrate menstrual health within SRH services, and why is this important? Here is an explanation from Funmi Olaolarun, a community health physician, researcher, and senior lecturer with the Department of Community Medicine at the University of Ibadan in Southwest Nigeria.
Funmi Olaolarun: For me, integration of family planning and menstrual health should include integration of programs, research, as well as policies. Anyone who comes to the family planning clinic should be exposed to menstrual health messages and services, and anyone who seeks out menstrual health information should be exposed to family planning counseling and services at the same visit in the same place.
Both family planning and menstrual health involve the lives and needs of women of reproductive age, and so integrated programs would be more cost effective than individual vertical programs, and I believe the overall program would be of greater interest to women and would meet them where they are.
Narrator: Marni Sommer, a professor of Sociomedical Sciences at the Mailman School of Public Health at Columbia University in New York City, also talked about the importance of integrating these services.
Marni Sommer: The menstrual cycle is about as fundamental as you get to your sexual and reproductive health. I think it is one of the most important things that someone who menstruates learns about, and understands, and recognizes what is normal and what is not normal in terms of bleeding, in terms of pain, in terms of what they experience, so that they can best take care of themselves and seek care and support if they need it. Ideally, even those who don't menstruate understand that, so that they can support those in their lives who do menstruate, and then as they become, or if they become sexually active, everybody has a good understanding of the role of the menstrual cycle in relation to fertility, including those who have struggled with infertility.
Why should menstrual health be integrated into family planning? I don't know how you plan a family if you don't understand the menstrual cycle. I don't know how you plan how to get pregnant or how to try and get pregnant or how to delay getting pregnant if the natural rhythms of your body aren't understood either by you or your partner. And so I think it is like the building block of being able to engage in family planning.
Narrator: Arundati Muralidharan is the founder of the Menstrual Health Alliance India and the coordinator of the Global Menstrual Collective. She outlined four main benefits of integrating menstrual health and SRH services. These benefits span from the individual level to the health system level. First, let’s hear about the individual level.
Arundati Muralidharan: Going back to the very basics, integrating MH and SRHR can strengthen a common understanding, an understanding of just a common biological process and reproductive and sexual health events across the life course. If we know what a period is and why it happens, if you understand your menstrual cycle, that can be so powerful that when you are thinking about family planning, when you are thinking about a sexual relationship, you can figure out, you know, if you should have sex during a particular period of time or what kind of contraceptive you can use and how that may affect your body.
Narrator: The second benefit she described relates to gender and social norms at the community level. Essentially, the same social norms influence SRH and menstruation, so there are huge opportunities in addressing them together.
Arundati Muralidharan: Social determinants and social norms and gendered inequalities that affect both menstrual health and SRHR. So integrating the two can really harness the efforts that are ongoing to tackle these shared social determinants and amplify multi-sectoral actions and interventions that may be required.
Narrator: Third, Arundati talked about service delivery at the health system level.
Arundati Muralidharan: I think that integration of MH and SRH can really leverage and also strengthen programmatic similarities to facilitate positive outcomes at scale and again, across the life course. And by this I mean that if you look at SRH interventions, they're looking at products and they're looking at services and especially health services in terms of treatment. Now, if as a girl or a woman I'm going for you know, like a contraceptive, a family planning method, then that's a moment at which that health facility and that healthcare provider can give me information about my body, about periods, about the menstrual cycle.
Narrator: In addition to what Arundati mentioned, there are further service delivery implications related to menstruation that impact family planning. For example, many family planning providers require that clients wait until the first day of their menstrual period to begin a new method of contraception. For those who want to use contraception and/or space pregnancies—particularly those who are seeking same-day provision of care—this can create a significant barrier. However, there are a number of tools that can help mitigate this barrier.
For example, FHI 360 developed a pregnancy checklist with simple questions that providers can ask to rule out pregnancy. Evidence has also shown that increasing the availability of low-cost, easy-to-use pregnancy tests in family planning programs can reduce barriers for contraceptive use among women who are not menstruating at the time of their appointment. Another FHI 360 tool, called the NORMAL job aid, contains guidance for providers to counsel family planning clients on bleeding changes associated with various contraceptive methods. We will delve into this topic more in our next episode.
Arundati also talked about the common goals related to sustainability, societal expectations, and rights.
Arundati Muralidharan: And lastly, I think it's a very high level outcome that we're looking towards, but integration can help us move towards those very common goals related to health and wellbeing, gender equality, as well as rights. So we're looking at those high level SDGs, integration can really help us get there.
Narrator: So far, our guests have outlined the key benefits of integrating menstrual health and SRH. However, menstrual health and SRH funding are often separate, and family planning services do not necessarily include menstrual health. Why is this? Marni shared her thoughts.
Marni Sommer: Why has menstrual health been ignored in family planning? That's a million dollar question. I have always been a bit gobsmacked, because to me it is so central. I think perhaps people oftentimes focus on, you know, resources are always limited.
A second reason could be what we found in the realm of menstrual health and hygiene, is that everybody just assumed people understood the menstrual cycle. That girls were being taught about their periods, that they understand the fluctuations of a menstrual cycle. Which frankly, I don't even think we understand the evidence on the fluctuations of menstrual cycles. Even very advanced people who are medical and work in this field. I think there's a lot we've left to learn.
Narrator: All of our guests mentioned the fact that menstrual health—and particularly the integration of menstrual health and SRH—is under-funded and under-researched. However, even though we do not have extensive data and evidence—as we do with, say, FP-HIV integration, we do know what some of the benefits are, as our guests have outlined.
But how can programs integrate these two health areas, in practice? Where should they start? According to Marni, integrated programs should start by engaging young people—for example, including menstrual health in comprehensive sexuality education (or CSE) programs for youth. CSE should include information on body literacy and fundamental discussions around not only understanding the biological processes that are happening during menstruation and their implications for pregnancy, but also how to manage side effects and bleeding so that those who menstruate are able to continue to engage in their normal routines.
Marni Sommer: I think you start with young people, early adolescents. Devoid of conversation about family planning, you just help them to understand their period and what it means and to feel good about it as best they can.
I think that it is just so very essential to sort of have the menstrual cycle incorporated and integrated in any kind of family planning work. And starting with the young age, making sure girls understand what a period is and why they're getting it with even just a droplet of understanding that one day this will influence or have a role in their pregnancy. And then you build on that knowledge over time to the point of when they're age-ready, socially-ready to understand it more deeply.
Narrator: Marni stressed that while it is important to start with young adolescents, this intersection of menstruation and fertility should be an important topic of SRH programs—and in primary health care—throughout an individual’s life course.
This understanding of the menstrual cycle is part of a concept known as “body literacy”—or developing an understanding of the body's natural rhythms, changes, and signals. While there are some common changes and signals that ovulation or menstruation is happening or about to happen (for instance, increased breast tenderness or shifts in moods), these rhythms and changes are unique experiences for every person who ovulates or menstruates, making body literacy a critical life skill to acquire at a young age. Arundati also spoke about this topic.
Arundati Muralidharan: In family planning programs, essential body literacy is critical. And when we do talk to girls and women about whatever contraceptive that they're using, the focus is more on what they're using and how it's helping them avoid a pregnancy, but they’re often kind of, unable to recall or communicate what's happening inside the body. So I think that we still have a fair bit of work to do to ensure that they have that understanding of what's happening in their bodies, what the cycle is, when they can get pregnant, and then how these contraceptives that they're using are enabling that.
Narrator: Arundati also explained the importance of integrating menstrual health into broader SRH programs and services beyond family planning—for example, programs that screen for breast cancer, cervical cancer, and other sexually transmitted infections.
Narrator: In addition to other SRH topics, menstrual health can also be integrated with multi-sectoral programming—including programs focusing on water, sanitation, and hygiene (or WASH). A number of programs—for example, USAID’s WASHPaLS in Nepal—have successfully integrated menstrual health with WASH activities.
Marni explained the connection between menstrual health and WASH interventions.
Marni Sommer: Because someone in family planning, let's say, or in the contraceptive community, is going to advocate for someone to use contraceptives or family planning, very much focused as they should be on sexual reproductive health and that person's needs. They may not be thinking about: does that person have adequate menstrual materials and access to toilets and water? If they're having a different kind of bleeding pattern than they would otherwise, do they have the privacy to manage that bleeding pattern in a way not everybody in the family notices and starts asking them questions? And so although menstrual materials and water and sanitation feel very far from family planning, I actually think that they're quite integral when you're looking holistically at asking somebody to engage in a way that might change their bleeding patterns.
Narrator: Arundati explained how this integration can benefit the larger SRH field as well.
Arundati Muralidharan: When we look at WASH interventions, we're often looking at water sanitation, hygiene (or WASH) interventions from a lens of menstrual hygiene. But this can also hugely benefit certain SRH conditions as well. You know, whether it's a woman who is pregnant, a woman who may have had an abortion, a woman who's having a prolapsed uterus, or a woman who's experiencing perimenopause. I mean, the same WASH intervention that we're looking at for menstrual health and hygiene is very applicable to people across these other phases of their lives and where they're experiencing very different but also very interlinked SRH issues.
Narrator: A final example of menstrual health and SRH service integration in action is related to addressing gender and social norms—specifically, how interventions that promote gender equality can support both menstrual health as well as SRH.
Arundati Muralidharan: You have social and behavior change communication interventions that have been done with menstrual health interventions as well. And they have actually helped to catalyze change or create an opening when it comes to talking about SRH issues.
So organizations that have very purposefully tried a social behavior change approach with menstrual health and hygiene– where they've looked at gender norms, they've tried to address those social norms. They've also been able to talk to these adolescent girls, and later young women, about how they can negotiate safe sex with their partners, how they can negotiate with their families about early marriage. So we are seeing that this kind of intervention can have that carried forward effect as well.
Narrator: One issue that was addressed by all of our guests was menstrual equity. Specifically, the importance of ensuring that menstrual health programs, products, and services are available to all who need them—including marginalized communities who may lack access to SRH programs in general. For example: LGBTQI+ individuals, those living in rural and remote areas, adolescents and young people, those living with disabilities, sex workers, and those living in humanitarian and crisis settings.
Reaching these groups can be challenging, and there are often missed opportunities for integrating menstrual health with other SRH services. Arundati provided a helpful example to put this issue into context.
Arundati Muralidharan: Just last year I was visiting a very remote tribal area. It took us six hours to get there, then it was a six kilometer walk from the last motorable point to get to those villages. And when you got there, you realize that there was no nearby health facility that was serving these women. I mean, they had access to no other service. So if we were going there with a health worker and she had that opening with that community to talk about immunization and to talk about family planning, then there was an opportunity for her also to provide that basic information on menstrual health and hygiene, which is a need for the girls and women of that community.
But for that health worker, that was not a part of her mandate. So she was going only with, “Okay, I need to talk about immunization for kids and I need to talk about family planning, especially to those who are like 15 to 25 years of age.” She acknowledged that menstrual health and hygiene was an issue, but just didn't have the tools or the information of what she could talk about and how she could talk about it.
Narrator: This is a powerful example of how systematic integration of menstrual health and SRH could make a huge difference.
In addition to remote areas, Arundati also discussed the importance of integrating menstrual health and family planning within crisis settings.
Arundati Muralidharan: In India we have refugees from neighboring countries who are living in pretty dismal conditions in these relief camps. And they're not camps that are for one week or two weeks. They've been living here for years, as in other parts of the world.
One NGO or one government service will go to them with reproductive and sexual health services. And another one will go to them for menstrual health and hygiene. And it's a lot for this community to take. And instead, if we are able to join forces, we'd probably be able to reach them better, serve them better, be able to make these connections between these two very interlinked issues. And you know, hopefully be able to promote health outcomes in a positive way for them.
India's a country where we face natural disasters. Routinely, annually, every year some of our sea facing states have cyclones, flooding. We've got other states that experience flooding and communities are displaced for, you know, anywhere between a few days up to a month. When they are displaced and staying in these kind of shelter areas, they need access to menstrual products and disposal facilities and wash facilities. But they may also require SRHR services, you know, for a pregnant woman, someone who's just given birth.
And integration of services to enable better delivery at this kind of juncture is also something that I think can be, you know, hugely beneficial.
Narrator: There are a number of tools that can provide guidance to groups working in SRH—including menstrual health—in emergency settings. Links to these tools can be found in the notes for this episode.
Finally, a fundamental part of menstrual equity is access to menstrual supplies. Approximately one-fourth of women and girls globally—an estimated 500 million individuals—do not have the supplies they need to manage their menstruation. These supplies include not only menstrual hygiene products like pads and tampons, but access to washing facilities and waste management. To make matters worse, menstrual supplies are often taxed as “luxury goods” and many people can not access or afford them.
Bringing menstrual health and family planning together can help better serve marginalized groups with holistic sexual and reproductive health. But how do we do this in practice? Here is Funmi with some recommendations for ways to start.
Funmi Olaolarun: I think the first step would be to identify the marginalized populations of interest. I know that no single program can reach all marginalized populations, but perhaps one is interested in people who are in hard to reach areas, or people with physical disabilities, or even adolescents. Then I would say to co-design packages with them after some initial baseline research to show that the proposed intervention actually helps to improve health outcomes.
Now having co-designed an intervention with them, it would be important to involve the marginalized groups in the implementation of the program or the intervention as well as the evaluation.
Narrator: Funmi mentions that co-creating and engaging marginalized groups from the beginning will increase engagement and reach for menstrual health and SRH integrated programs.
Marni also talked about reaching marginalized groups—particularly those who identify as LGBTQI+.
Marni Sommer: So in thinking about how sexual and reproductive health and menstrual health can better reach traditionally marginalized populations, in particular trans and gender expansive populations– so I think overall we have to do a better job. We're not even reaching non-marginalized populations particularly well.
When you're speaking of trans and gender expansive populations, either a teacher or provider who's not well-versed in speaking to the issues or thinking more expansively, may not think to include everybody or ask the right questions.
And one of the things that, a number of years ago, a master student and I did a study (this was his idea, it was a great idea) with transgender non-binary folks and their providers in the New York City area. And what we were quite astounded to discover was a lot of the providers who were very good that they themselves were not given training on how to ask about or talk about periods.
The folks we see are transitioning and so we immediately start to talk about hormones and we don't talk about the experience of their period. But that just seemed to be inadequate from our perspective and from the perspective of the trans and gender non-binary folks who we interviewed. And so we ultimately developed a provider guide because we thought, both for the terrific and already strong clinicians ranging from therapists to medical providers in these clinics here in New York, but also those working in other parts of the country or the world who may not encounter as many diverse folks and may not have the feel; who don't ask, not because they don't want to ask and talk about menstrual health and sexual and reproductive health, but don't feel they have the right language and don't want to offend. And so we developed a provider guide with language suggestions and suggestions for how the environment of the clinic should be designed to be as friendly as possible.
Narrator: Menstrual health is an important area of SRH—but it continues to be under-funded, under-researched, and under-programmed. It is important that the global SRH community continues to advocate for more attention, research, and funding to ensure that menstrual health programs are part of holistic SRH care.
Join us for our next episode, where we will continue exploring issues related to menstrual health and SRH—specifically, contraceptive-induced menstrual changes.
Season 6 of Inside the FP Story is produced by Knowledge SUCCESS and FHI 360. This episode was written by Sarah Harlan and edited and mixed by Elizabeth Tully. It was supported by an additional team, including Emily Hoppes, Catherine Packer, and Brittany Goetsch.
Special thanks to our guests Arundati Muralidharan, Funmi Olaolarun, and Marni Sommer.
To download episodes, please subscribe to Inside the FP Story on Apple Podcasts or Spotify; and visit knowledgesuccess.org for additional links and materials.
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.
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