The Integration of Family Planning with Other Health

Services:A Literature Review

CONTEXT: Integrating family planning services with other health services may be an effective way to reduce unmet By Anne Sebert
need.However,greater understanding of the evidence on integration is needed. Kuhlmann,
Loretta Gavin and
METHODS: Studies that evaluated the integration of family planning with any other type of health service were identi- Christine Galavotti
fied by searching five databases.To be included,studies had to have: been published in English between 1994 and
2009; used either a single-group pre- and posttest design or a two-group control or comparison design; and reported a
Anne Sebert
family planning–related behavioral or reproductive health outcome. Kuhlmann is an inde-
pendent consultant,
RESULTS: Nine studies met the inclusion criteria.The integration interventions ranged from simple referrals between MANILA Consulting
providers of existing services to fully integrated,community-based delivery of education and services.One evaluation Group, Inc., McLean,
used a quasi-experimental design; two used case-control comparison designs; two used combination designs; and the VA, USA. Loretta
Gavin is health
rest used either a single-group pre- and posttest design or a two-group cross-sectional design.Seven studies found im- scientist, Division of
provements in family planning–related outcomes,although not all reported the significance of these changes; anoth- Reproductive Health,
er reported mixed results and one found no effect.Of the studies that examined providers’, clients’or community mem- and Christine
bers’perspectives of integration,all reported overall satisfaction.No studies provided an economic analysis. Galavotti is chief,
Applied Sciences
Branch, Division of
CONCLUSIONS: The evidence supporting the integration of family planning with other health services remains weak, Reproductive Health—
and well-designed evaluation research is still needed.Future research should report outcomes for all health areas both at the Centers for
being integrated and should investigate in more detail the perspectives of providers,clients and community members Disease Control and
and assess the cost-effectiveness of integration. Prevention, Atlanta,
International Perspectives on Sexual and Reproductive Health,2010,36(4):189–196 GA, USA.

Despite decades of progress in improving the delivery and childhood immunization programs10 or intimate partner
availability of family planning services, high levels of unmet violence programs.11 Another study reviewed the integra-
need for family planning still exist in many countries.1 This tion of primary health care services in general.3 To our
suggests that novel approaches are needed to extend access knowledge, however, no comprehensive review has been
to family planning services to women and couples who de- conducted examining integration of family planning ser-
sire to limit or space their childbearing but are not currently vices with any type of health service. Therefore, we re-
using contraceptives. The integration of family planning viewed the literature to understand the current state of
with other health services may be one such approach. Al- knowledge about the effectiveness of such integration.
though integration may seem logical, the results of efforts
to integrate child2 or primary3 health care services with METHODS
other services suggest that integration presents many lo- We searched the peer-reviewed literature to identify quanti-
gistic challenges and that caution is advisable. Shelton and tative studies conducted anywhere in the world that evalu-
Fuchs warn that the fragility of health systems in many ated the integration of family planning services with any
countries can constrain effective integration of services.4 other type of health service. We established, a priori, two in-
Therefore, an evidence base demonstrating the effective- clusion criteria for the studies in this review. First, the study
ness of integration needs to be established before substan- had to report a family planning–related behavioral or re-
tial investments are made in promoting integration as a productive health outcome, such as contraceptive preva-
means of fulfilling unmet need for family planning. lence or service utilization. Second, the evaluation study had
Numerous studies have examined the integration of to have either a single-group pre- and posttest design or a
family planning with programs for HIV/AIDS or other two-group control or comparison design. These criteria were
STIs.5–9 Other studies have explored integration of health established to make it easier to assess the strength of evi-
services (in some cases family planning services) with dence regarding the effectiveness of integration.
The search covered five databases that abstract peer-
reviewed journals relevant to public health: PubMed, Em-
*We initially searched the Global Health database, which was subsumed
under CABDirect during the course of the review. base, CABDirect,* PsycINFO and Social Sciences Citation

Volume 36, Number 4, December 2010 189

Integration of Family Planning with Other Health Services: A Review

Index. We selected these databases to capture a broad at certain times. More than one of these approaches to in-
range of geographic and disciplinary areas. To search the tegration may be implemented simultaneously.
databases, we used the combination of a family plan- We used a tiered system adapted from the Guide to
ning–related term (“family planning,” “birth spacing,” Community Preventive Services to rate the strength of each
“birth control,” “contraception,” “pregnancy planning” or evaluation’s design.12 The Guide presents a well-established
“pregnancy prevention”) and an integration-related term system developed by the Centers for Disease Control and
(“integration,” “bundling” or “twinning”). We limited the Prevention and its partners for reviewing evidence-based
search to articles published in English from 1994 to mid- public health information. Our adaptation classified the
2009. At first, we conducted the search using a 10-year pe- strength of a study’s design as being at one of four levels:
riod (1999–2009), but because the number of eligible arti- greatest, moderate, fair or least. Study designs categorized
cles was small, we expanded the search period to 15 years. as having the greatest strength used “concurrent compari-
Our search identified 581 unique abstracts, of which 80 son groups and prospective measurement of exposure and
were relevant to our topic. Two of us (ASK and LG) sepa- outcome.”12 The moderate tier consisted of retrospective de-
rately reviewed all relevant articles for inclusion, reaching signs, including case-control comparison designs. We la-
consensus through discussion. Of the 80, many were com- beled studies that combined a single-group pre- and posttest
mentaries or descriptive cross-sectional studies that did not design with a cross-sectional comparison group, or that
meet the inclusion criteria. Ultimately, nine articles met both used multiple pre- and posttests without a comparison
inclusion criteria and are included in the present analysis.* group (i.e., time series), as fair. Finally, those that used “sin-
In reviewing the nine articles, we paid special attention to gle pre- and postmeasurement and no concurrent compar-
the integration intervention and its evaluation. We could not ison group” or a two-group cross-sectional design were con-
identify an agreed-upon set of terms describing the distin- sidered the least suitable for contributing to an evidence
guishing features of integration efforts, so we named and de- base.12 Studies with weaker designs, such as single-group
fined several potential approaches to integration before con- cross-sectional, were not included in the review.
ducting the review. In an iterative process, we then refined Finally, to examine the effect of the integration inter-
the terms and their definitions to reflect how integration vention on family planning–related outcomes, we assessed
was implemented in the various studies. the magnitude and statistical significance of the reported
The intervention characteristics that we considered in- changes in contraceptive prevalence or service utilization.
cluded the type of health service that was integrated with If reported, the magnitude and statistical significance of
family planning, the location of the integration (clinic, com- changes in outcome variables for the other (nonfamily
munity or both) and the integration approach (Web Ap- planning) health services were assessed as well. We also
pendix Table 1). We classified integration approaches into noted whether studies reported clients’, providers’ or com-
five categories: referrals, community partnerships, service munity members’ perspectives of the integrated services.
coordination, cross-training and structural approaches. In
referral-based interventions, staff members providing one RESULTS
type of service encourage clients to receive or obtain the Of the nine articles included in the review, eight were pub-
other service(s) from a separate set of providers in a clinic lished between 1999 and 2009. The nine studies suggest
setting. In community partnerships, staff who provide a that the integration of family planning with other health
clinic-based service refer clients to specially trained com- services is taking place around the world, as Sub-Saharan
munity members or outreach workers to obtain one or Africa, Southeast Asia and South and Central America are
more other services outside of the clinic setting (and vice all represented (Table 1). All of the studies were conduct-
versa). Service coordination entails clients’ receiving mul- ed in developing countries, although this was not a crite-
tiple services delivered by multiple providers at the same rion for inclusion.
site during a single visit (i.e., the “one-stop shopping”
model). Cross-training involves expanding the training of Location and Approach
staff so that they are able to provide more than one type of The studies included both clinic- and community-based
health service to a client during the same visit. Finally, interventions, used a variety of approaches (Table 1) and
structural integration refers to changing the infrastructure were integrated with a wide range of other health services
and administration of the relevant health services in order (Table 2, pages 192–193). Most frequently, family plan-
to make them more seamless—for example, by creating a ning was integrated with some type of existing health ser-
single medical record for mothers and infants or eliminat- vice for mothers, children or both, such as the Expanded
ing rules by which family planning services are offered only Programme on Immunizations. Other interventions inte-
grated family planning with existing services for sexually
active women, such as HIV/AIDS programs.
*Of the 71 remaining articles, 11 were reviews related to other topics or
aspects of integration,20 were editorials or commentaries on integration, Two studies13,14 went beyond the typical focus of fami-
15 described general approaches to service delivery or integration (or ly planning integration efforts by integrating family plan-
tests of such approaches) and 25 detailed specific program experiences
but either lacked a pre-post design or comparison group (11) or did not ning with broad health interventions. Lundgren and col-
report any family planning outcomes (14). leagues reported on an intervention in El Salvador that, in

190 International Perspectives on Sexual and Reproductive Health

 TABLE 1. Selected characteristics of studies assessing the impact of integrating family planning services with other health services, 1994–2009, by
strength of study design

Study Country Strength Location Approach Family planning outcomes

of study
design Clinic Com- Referrals Community Service Cross- Structural Improve- Statistical
munity partnerships coordi- training ments significance
nation reported reported
Huntington Togo Greatest X X Yes Yes
and Aplogan,199418

Alvarado Chile Moderate X X X X X No No

et al.,199915

Fullerton Ghana Moderate X X Yes Yes

et al.,200319

Bossyns Niger Fair X X X Yes No

et al.,200216

Lundgren El Salvador Fair X X Mixed Yes

et al.,200514

Amin Bangladesh Phase 1:Fair X X X Phase 1:Yes Phase 1:No

et al.,200113 Phase 2:Least Phase 2:Yes Phase 2:Yes

Adeokun Nigeria Least X X X Yes No

et al.,200217

Douthwaite Pakistan Least X X Yes Yes

and Ward, 200520

Paxman India Least X X Yes No

et al.,200521

an attempt to expand family planning participation among members refer clients to specially trained community
men, integrated family planning education and referrals members or outreach workers for additional services.
with an existing water and sanitation program that in- In addition to the Chile study, two other interventions
cluded home visits and community meetings.14 Amin and involved substantial structural changes in how services
colleagues described a collaboration in Bangladesh be- were organized and administered. In Niger, special family
tween a nongovernmental organization and the local gov- planning clinics were abolished, and services were instead
ernment to provide microcredit assistance and childhood offered at a broader range of times and locations.16 In Nige-
immunizations along with family planning education and ria, an integrated management information system for fam-
referrals and nonclinical family planning commodities.13 ily planning and prevention of HIV and other STIs was de-
Although many interventions had an explicit commu- veloped and implemented.17
nity component designed to reach potential family plan-
ning clients who might otherwise be missed by a static, Strength of Evaluation Study Designs
clinic-based program, the extent of this component ranged The study by Huntington and Aplogan was the only one
widely, from health workers making home visits to com- that met the criteria for having the greatest strength of
munity mobilization. In addition, two studies combined study design; it was also the earliest published (1994).18
clinic and community-based intervention strategies. In the Both of the studies that received a moderate rating used
first, Alvarado and colleagues tested an intervention in case-control comparison designs, although the quality of
Chile that trained community health workers to make the comparison group differed between the studies: The
home visits to pregnant women; the intervention also in- intervention and comparison groups were more compa-
volved structural changes in clinic procedures, so that rable in Ghana than in Chile, and the Ghana study used a
mothers and infants shared a clinical record and had dual random sampling strategy whereas the Chile study used
appointments during the postpartum year.15 In contrast, convenience sampling.15,19 Two of the three studies that
the Bangladesh study started as a door-to-door interven- received a fair rating13,14 combined single-group pre- and
tion but shifted to include static, clinic-based integration.13 posttest measurement with two-group cross-sectional de-
The methods of delivering integrated services varied. signs by conducting baseline surveys only with potential
The five studies that featured community partnerships fol- participants but then including both participants and non-
lowed the model of having specially trained community participants in the follow-up survey; the third used multi-
members or outreach workers provide information, edu- ple pre- and posttest measurements (i.e., time-series de-
cation and nonclinical services, while providing referrals sign) but did not include a comparison group at any
for clinical services; none mentioned having clinic staff measurement point.16

Volume 36, Number 4, December 2010 191

Integration of Family Planning with Other Health Services: A Review

TABLE 2. Interventions, designs and results of studies assessing the impact of integrating family planning services with other health services,
1994–2009

Study Intervention Study design, data collection and sample Family planning and other outcomes
Adeokun et • Family planning providers were • Single pre- and posttest design using mixed • The proportion of visits at which condoms were distributed
al.,200217 trained to counsel clients on dual methods;no comparison group increased from 2% to 9% (p value not reported)
protection and provided female • At baseline,evaluators made structured • The proportion of new clients aware of dual protection increased
condoms (initially free,then for observations of 325 provider-client interactions from 8% to 50% (p value not reported)
$0.10),as well as HIV/STI and conducted exit interviews with 175 clients; • The proportion of new client visits in which tailored dual protection
prevention counseling at follow-up,they observed 289 provider-client counseling was provided increased from 28% to 67% (p<.05)
• A management information interactions, conducted exit interviews with
system that included dual 289 clients,interviewed 10 providers and con-
protection was developed and ducted focus groups with providers,clients
implemented and male community representatives
•Providers were supervised by • Service statistics were collected from all clinics
and met monthly with the training • Service providers interviewed 47 dual-
organization protection acceptors at follow-up

Alvarado et • Providers and community • Case-control design • Proportion of women who initiated contraception during the
al.,199915 health workers in maternal and • Clinical record review of 200 women living in postpartum year was similar for intervention and control clinics
child health and reproductive intervention clinic neighborhood who had a (92% vs.96%;p value not reported)
health altered their procedures pregnancy and 200 mothers and infants attending • Providers and clients at intervention clinic reported high levels of
so that mothers and infants were first postnatal follow-up visit at control clinic satisfaction with the program (those at control clinic were
seen during the same visit, • Investigators conducted in-depth interviews not surveyed )
shared a common clinical record with 35 women attending intervention clinic • At six months postpartum,74% of infants at intervention clinic
and had the same number of and four providers at the clinic,as well as three and 10% of those at control clinic were exclusively
postpartum follow-up visits focus groups with women attending the clinic breast-fed (p=.0001)
• Community health workers • Despite similar birth weights and lengths,infants at intervention
conducted individual and group clinic were heavier and longer than those at control clinic at
counseling,including two six months (p=.03 and p<.001,respectively) and 12 months
prenatal home visits,a maternity (p<.001 for both)
ward visit and monthly
postpartum group sessions

Amin et • Intervention integrated family • In phase 1,single pre- and posttests were done • In phase 1,contraceptive prevalence increased from 28% to 53%
al.,200113 planning with microcredit and in experimental areas (656 and 2,105 women among women in experimental areas and was higher in
childhood immunization surveyed,respectively),and posttests were done experimental than control areas (53% vs.38%);p values were
programs in comparison areas (1,721 women) not reported.
• In phase 1,door-to-door • In phase 2,a posttest survey was conducted • At end of phase 2,microcredit members were more likely than
education campaigns delivered among 1,068 women in experimental areas and nonmembers to report current contraceptive use (odds ratio,1.5;
nonclinical family planning and 700 women in comparison areas p<.01) and to use a static clinic for family planning (1.70;p<.05),after
child immunizations;group adjustment for background characteristics
meetings were held among • Diphtheria,pertussis and tetanus immunization coverage among
microcredit recipients chIldren increased in experimental areas from 83% to 94%,
• Phase 2 added a package of but was similar at follow-up to coverage in control areas (96%).
clinic-based curative care and Similarly,coverage of tetanus immunization among women
child and reproductive health increased in experimental areas from 81% to 90%,but was similar
services at follow-up to coverage in control areas (86%);p values were
not reported.

Bossyns et • Family planning services were • Multiple pre- and posttest design;no •
Annual no.of couple-years of contraceptive protection increased
al.,200216 integrated with curative comparison group between the three years before the intervention (487–566) and the
services,postnatal care and • Data obtained from five years of district service two years after (920–1109).
consultations for children •
utilization statistics (intervention was implemented The annual no.of new contraceptive users also increased,from
younger than 5 at the end of the third year) and from direct 489–568 to 1,496–1,509.
• New operational instructions observation in three health centers before •
P values were not reported for either outcome
were created,including (N=277) and after (N=403) implementation •
Non-family planning outcomes not reported
procedural changes (e.g.,
provision of six cycles of
contraceptives),structural
changes (e.g.,elimination of
dedicated family planning
clinics) and attitudinal changes
(e.g.,offering family planning to
all eligible women)
• Monthly supervisory visits to
all health centers

Douthwaite • Lady Health Workers delivered •Posttest design in intervention and comparison • Proportion of women using modern contraceptives was higher in
and Ward, maternal and child services in areas intervention areas (20%) than in control areas (14%) or in a national
200520 homes and were responsible for •Sample consisted of 3,346 married rural women survey (15%;p values not reported)
promoting use of family planning, aged 15–49 in intervention areas and 931 such • Women in intervention areas were more likely than those in control
providing pills and condoms,and women in control areas areas to report use of modern reversible contraceptives (adjusted
making referrals for injections, •Additional comparisons made with national odds ratio,1.50;p=.03)
IUDs and sterilization survey • Non–family planning outcomes not reported

192 International Perspectives on Sexual and Reproductive Health

 TABLE 2. contInued

Study Intervention Study design, data collection and sample Family planning and other outcomes
Fullerton et • Family planning providers in • Case-control design;conducted in 1996–1998 •Annual no.of family planning clients increased in case facilities
al.,200319 eastern Ghana were trained to • Data obtained from observations in 24 intervention (from 2,300 to 3,000) but showed little change in comparison
integrate STI and postabortion and 19 comparison facilities,clinical record reviews facilities (from 2,600 to 2,700);p values not reported
care into service delivery in all facilities,and interviews with 48 providers or •No.of continuing family planning clients seen per month increased
• Training targeted providers in clinic managers and 37 clients in case facilities (from 113 to 164;p=.02) but not in comparison
selected districts in region facilities; however,the no.of new or continuing clients did not differ
between case and control facilities
•No.of case facilities providing STI services increased from 6–7 to
10–11,and annual no.of STI clients at these facilities increased from
50 to 340;only two comparison facilities provided STI services
•Intervention facilities provided postabortion care to 136–426 clients
per year;no comparison facilities reported providing such services

Huntington • Before administering vaccines •

Two-group,quasi-experimental design • Proportion of women who reported that family planning was
and Aplogan, as part of the Expanded •
Stratified sample of 16 urban and rural clinics, mentioned during EPI services increased from 9% to 21%
199418 Programme on Immunizations which were randomly assigned to be test or control in test clinics but was stable (about 9%) in control clinics
(EPI),providers made three simple clinics (randomization procedures not described) (p value not reported)
statements referring mothers to •
Pre- and posttest exit interviews were conducted • Mean no.of new family planning acceptors per month increased
family planning services available with 1,000 randomly selected mothers whose in test clinics (from 200 to 307;p<.001) but not in control clinics
at the same visit and facility children had been vaccinated (randomization • Mean no.of family planning clients per month increased in test
(but from different providers) procedures not described) clinics (from 1,035 to 1,311;p<.0001) but not in control clinics
•
Posttest,self-administered questionnaires • Mean no.of vaccine doses administered per month increased
were completed by all EPI providers in test clinics in both test and control clinics
•
Service utilization data obtained from all clinics • Ninety percent of EPI providers felt referrals affected EPI
consultations;of these,96% thought the effect was positive

Lundgren et • Integration incorporated family • Single pre- and posttest in intervention • Prevalence of contraceptive use in intervention area increased from
al.,200514 planning services (provision of area,plus posttest with comparison group 44% to 63% (p≤.001) among men but did not increase among
information,condoms,CycleBeads • Independent samples of households were women
and referrals) with existing water surveyed at baseline (N=341) and follow-up • At follow-up,contraceptive use among those exposed to the
and sanitation projects in rural (N=364) intervention was similar to that among those not exposed
villages for both women (57% vs.48%) and men (65% vs.62%)
• Community members were • Non–family planning outcomes were not reported
educated through group talks by
NGO staff and volunteers,and
home visits by trained volunteers

Paxman et • Family planning integrated • Single pre- and posttest design • Contraceptive prevalence increased by 10–39 percentage points
al.,200521 with child health services • Three NGOs working in different project areas each in the three project areas (p values not reported)
through India’s Local Initiatives conducted baseline and follow-up surveys and • The proportion of pregnant women who received complete antenatal
Program had leeway to implement their own approach and care services increased by 22–49 percentage points in the three areas
• Program partnered community instrument;two used the World Health Organization (p values not reported)
teams with government health •
and 30-household-cluster survey approach,and the The proportion of children fully immunized increased by 27–42
staff,development workers and other used a baseline sample of 7,400 men and percentage points in the three areas (p values not reported)
local leaders;community members women
were involved in planning,imple- • Other details about survey design,sample size
mentation and resource and sample characteristics not provided
mobilization • Additional comparisons made to a national
• Women received information, survey conducted around baseline
clinic referral and resupplies of
pills and condoms

Outcomes planning clients in intervention clinics, while the compar-

•Family planning—related measures. Studies of interven- ison clinics reported no such increases. In Pakistan, use of
tions that focused on clinic-based components tended to reversible, modern contraceptives was significantly greater
report service utilization outcomes, while those with com- among respondents in intervention areas than among
munity-based components tended to report contraceptive those in comparison areas, even after adjustment for com-
use or prevalence data. Seven studies13,16–21 reported im- munity, household and individual characteristics.20 All
provements in a behavioral or reproductive health out- three studies reported the statistical significance of their
come related to family planning, although not all of these family planning–related outcomes.
studies reported the significance of these improvements. Several other studies reported large percentage point in-
The other two reported either mixed results in family plan- creases in family planning–related outcomes. For example,
ning–related outcomes14 or found no improvements in self-reported contraceptive prevalence increased by 10–39
these outcomes.15 No study reported that integration had percentage points in India21 and by 25 percentage points
a negative impact on a family planning–related outcome. in Bangladesh;13 the number of family planning visits in
The quasi-experimental study and one of the case- which condoms were distributed increased by approxi-
control studies reported statistically significant increases mately seven percentage points in Nigeria;17 and a com-
in the mean number of new18 and continuing19 family posite index of contraceptive uptake increased from less

Volume 36, Number 4, December 2010 193

Integration of Family Planning with Other Health Services: A Review

than 1% to 23–29% in Niger (not shown).16 The statisti- their location and the approach to integration all varied.
cal significance of these increases was not reported, how- This lack of consensus about the nature of integration
ever, making it difficult to assess their relevance. complicates the dialogue about how best to do it. As dis-
Lundgren and colleagues reported mixed results in fam- cussions concerning the value of integration and its various
ily planning–related outcomes.14 They found an increase forms continue, there is a need to refine definitions of inte-
in self-reported contraceptive use among male program gration and to clarify approaches. As an initial step toward
participants, but not among female participants. Further- a common taxonomy, we have presented terminology to
more, at follow-up, contraceptive use did not differ be- classify the various locations and approaches. This taxono-
tween program participants and nonparticipants among my may need to be refined and expanded as our knowledge
either men or women. Moreover, because of the study de- about integration increases; however, the use of common
sign, the possibility cannot be ruled out that the changes terminology should make it easier to develop an evidence
in men’s contraceptive use at follow-up were due to his- base for integration and for providers, program implemen-
torical events in El Salvador instead of the intervention. tation staff and researchers to share experiences.
Alvarado and colleagues’ case-control study of service Although it makes sense that integration should result
integration in Chile15 did not find a positive effect on any in fewer missed opportunities for providing relevant ser-
family planning–related outcome. The contraceptive initi- vices, and in potentially greater efficiency in service deliv-
ation rate in the intervention clinic was similar to that in ery, the data supporting these claims remain insufficient.
the comparison clinics, despite the availability of a broad- Our study, like previous reviews of integration efforts,3,7
er range of contraceptive methods at the intervention clin- found that the overall quality of the studies was often poor,
ic. Furthermore, the intervention clinic initially offered as many had a single-group or cross-sectional design.
contraceptives free of charge, while the comparison clinics Thus, although these studies contribute to the knowledge
charged a small fee. However, the intervention clinic did base about integration and can help generate hypotheses
report significantly better outcomes than the comparison for future research, their contribution to establishing an
clinic on measures of exclusive breast-feeding and infant evidence base on the effectiveness of integration in im-
weight and length. proving family planning outcomes is limited. Of note,
•Other outcomes. Some studies reported indicators of in- however, is that two of the three studies with the strongest
tegration success and acceptability beyond those related designs reported significant improvements in family plan-
to family planning (e.g., outcomes for other health ser- ning–related outcomes.
vices, client perspectives of the integrated services). All six While the general weakness of the study designs limits
of the studies that reported outcomes related to the other one’s ability to establish causality, the consistency of the
health services involved in the integration reported im- results suggests that integration has positive effects on
provements in those outcomes.13,15,17–19,21 However, the family planning–related outcomes. Summarizing the over-
significance of these findings was not always reported. all magnitude of those effects is difficult, however, because
Similarly, all three of the studies that reported of differences in approaches, study designs, outcome vari-
providers’, clients’ or community members’ perspectives ables and reported information. This review highlights the
concerning the integration intervention found positive re- need for well-designed, well-executed evaluation research
actions (not shown).14,15,18 In El Salvador, nearly all par- to determine the effectiveness of integration and the best
ticipants thought integrating family planning information approaches to implementation.
into water and sanitation programming was beneficial.14 Several factors may be contributing to the dearth of
In Togo and Chile, most providers felt that integration en- high-quality evaluation research on integration. First, in
hanced service provision.15,18 However, the studies that re- the wake of the 1994 International Conference on Popu-
ported clients’ and providers’ reactions to the intervention lation and Development, integration has often been as-
provided only limited information; for example, they did sumed to be an effective strategy (although some have cau-
not discuss providers’ or participants’ perceptions of the tioned against this assumption4). In an environment
potential disadvantages and challenges of integration. where integration is thought to be an inherently positive
model of service delivery, investing time and resources in
DISCUSSION high-quality evaluation may not be a priority. Second,
Evaluations of integration efforts have been conducted donor commitment to family planning as a global public
around the world, and these interventions have taken var- health issue waned during the years covered by this re-
ious forms. Most efforts focused on integrating family view,22 potentially further decreasing the resources avail-
planning with other reproductive, sexual or child health able for evaluation research on family planning–related in-
services, but a few attempted to integrate family planning tegration. Finally, integration interventions often include
with services that extended beyond traditional health pro- a community component, and designing and implement-
vision. Furthermore, no single model of integration exists. ing evaluations that include adequate comparison or con-
Although all of the interventions integrated, bundled or trol groups in a community setting can be challenging.
paired different health services with family planning, each While this review included only a small number of stud-
did so in a unique way—the services that were integrated, ies, the three that had the strongest study designs were pri-

194 International Perspectives on Sexual and Reproductive Health

marily clinic-based interventions; three of the four with the beneficial. However, before integration is embraced as a
weakest designs were exclusively community-based inter- broad-scale strategy to address the high levels of unmet
ventions or had a significant community component. need for family planning around the world, well-designed
The studies reviewed here were selected, in part, because and properly executed evaluation research is needed to es-
they reported a quantitative outcome relevant to family tablish an evidence base for integration. Future research
planning programs. Other indicators of potential program should investigate providers’, clients’ and community
success and acceptability are also important to understand. members’ perspectives on the integrated services, report
Although data were limited, most providers, clients and health outcomes for all services being integrated and eval-
community members reacted favorably to integration ef- uate the cost-effectiveness of integration. Understanding
forts. Future research should include further assessment of the impact of various integration strategies on expanding
clients’, providers’ and community members’ perspectives the reach of services, on the efficiency and costs of service
on integrated services, such as their views concerning the delivery and on the overall impact on both family planning
conditions under which integration may or may not be fea- and other health outcomes would be extremely useful.
sible or acceptable (e.g., at fixed locations vs. outreach ses- The potential for benefit is clear, but the evidence base for
sions), ways to avoid or offset potential costs of integration whether and how to most effectively implement integra-
(such as long waiting times) and strategies for better inte- tion to obtain those benefits remains weak.
grating clinic- and community-based services.
Where reported, the other health services that were in- REFERENCES
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Volume 36, Number 4, December 2010 195

Integration of Family Planning with Other Health Services: A Review

15. Alvarado R et al., Integrated maternal and infant health care in the portaron la significancia estadística de esos cambios; otro más
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ics in Ibadan, Nigeria, International Family Planning Perspectives, 2002,
planificación familiar con otros servicios de salud sigue siendo
28(2):87–95.
débil; y todavía se necesita investigación evaluativa bien dise-
18. Huntington D and Aplogan A, The integration of family planning
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19. Fullerton J, Fort A and Johal K, A case/comparison study in the deben investigar en mayor detalle las opiniones de prestadores
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Pakistan: an evaluation of the Lady Health Worker Programme, Health RÉSUMÉ
Policy and Planning, 2005, 20(2):117–123. Contexte: L’intégration de services de planification familiale
21. Paxman JM et al., The India Local Initiatives Program: a model for aux autres prestations de santé peut être un moyen efficace de
expanding reproductive and child health services, Studies in Family réduction du besoin non satisfait. Une meilleure compréhen-
Planning, 2005, 36(3):203–220.
sion des données d’intégration est cependant nécessaire.
22. Speidel JJ et al., Making the Case for U.S. International Family Méthodes: Les études qui évaluent l’intégration de la planifi-
Planning Assistance, Baltimore, MD, USA: Population Reference Bureau,
2009, <http://www.prb.org/pdf09/makingthecase.pdf>, accessed cation familiale à tous autres types de prestations de santé ont
Aug. 31, 2010. été identifiées par recherche dans cinq bases de données. Les
23. Pronyk PM et al., A combined microfinance and training interven- critères d’inclusion suivants ont été appliqués: publication en
tion can reduce HIV risk behaviour in young female participants, AIDS, anglais entre 1994 et 2009; plan pré- et posttest à groupe
2008, 22(13):1659–1665.
unique ou plan de contrôle ou comparaison à deux groupes; et
24. Dickersin K, Min Y-I and Meinert CL, Factors influencing publica- rapport de résultat comportemental ou de santé génésique lié
tion of research results: follow-up of applications submitted to two in-
stitutional review boards, Journal of the American Medical Association, à la planification familiale.
1992, 267(3):374–378. Résultats: Neuf études se sont avérées conformes aux critères
d’inclusion. Les interventions d’intégration vont de simples ser-
RESUMEN vices d’orientation entre prestataires de services existants à
Contexto: Integrar los servicios de planificación familiar con l’intégration totale d’une éducation et de services communau-
otros servicios de salud puede ser una forma efectiva de reducir taires. Une évaluation repose sur un plan quasi-expérimental;
la necesidad insatisfecha. Sin embargo, se requiere una mayor deux sur un plan de comparaison avec contrôle; deux sur un
comprensión de la evidencia existente sobre la integración. plan combiné; et le reste soit sur un plan pré- et posttest à
Métodos: Se identificaron mediante la búsqueda en cinco bases groupe unique ou un plan transversal à deux groupes. Sept
de datos los estudios que han evaluado la integración de la pla- études observent des améliorations de résultats ayant trait à la
nificación familiar con cualquier otro tipo de servicio de salud. planification familiale, bien qu’elles ne fassent pas toutes état
Para ser incluidos, los estudios tenían que haber: sido publica- de l'importance du changement observé; une fait état de résul-
dos en inglés entre 1994 y 2009; haber usado un diseño ya sea tats mixtes et une n’observe aucun effet. Parmi les études pré-
de grupo simple pre y post prueba, o un diseño de control y com- sentant les perspectives des prestataires, des clientes ou des
paración de dos grupos; y haber reportado un resultado de com- membres de la communauté sur l’intégration, toutes font état
portamiento relacionado con la planificación familiar o con la d’une satisfaction générale. Aucune des études ne présente
salud reproductiva. d’analyse économique.
Resultados: Nueve estudios cumplieron con los criterios de in- Conclusions: Les données au soutien de l’intégration de la
clusión. Las intervenciones de integración variaron desde sim- planification familiale aux autres services de santé demeurent
ples referencias entre prestadores de servicios existentes, hasta faibles et une recherche d’évaluation bien conçue reste néces-
la suministración comunitaria de educación y servicios com- saire. La recherche à venir devra faire état des résultats obser-
pletamente integrados. Una evaluación usó un diseño cuasi-ex- vés sur tous les plans de santé intégrés. Elle devra examiner de
perimental; dos usaron diseños comparativos caso-control; dos manière plus approfondie les perspectives des prestataires, des
usaron diseños de combinación; y el resto usó un diseño ya sea clientes et des membres de la communauté et évaluer la renta-
de grupo simple pre y post prueba, o un diseño transversal de bilité de l’intégration.
dos grupos. Siete estudios detectaron mejoras en los resultados
relacionados con la planificación familiar, aunque no todos re- Author contact: [email protected]

196 International Perspectives on Sexual and Reproductive Health