School-based health centers with reproductive health services

There is some evidence that school-based health centers (SBHCs) that provide reproductive health services increase contraceptive use (Bersamin 2018, Fisher 2019), particularly among teenaged girls (CG-SBHC, Boniface 2021, Keeton 2012, Ethier 2011); and reduce teen birth rates (Fisher 2019, NBER-Lovenheim 2016, Owen 2010, Ricketts 2006), especially among Black and Hispanic youth (NBER-Lovenheim 2016). However, additional evidence is needed to confirm effects.

SBHCs that prescribe and dispense contraceptives appear to increase the use of contraceptives more than SBHCs that do not (Bersamin 2018, Blank 2010). More SBHCs are providing long-acting reversible contraceptives (LARCs) as part of their reproductive health services (Boniface 2021); LARCs include intrauterine devices (IUDs) and contraceptive implants (CDC-Contraception). Students appear to find SBHCs’ provision of IUDs acceptable and be satisfied with their care (Stein 2020). Additional contraceptive training for SBHC providers appears to increase the use of LARCs (Comfort 2021), and experts recommend onsite training of providers and staff, support from school administrators, and patient-centered contraceptive counseling to support successful implementation of LARC services at SBHCs (Summit 2019). A Texas-based study suggests that SBHCs may increase access to LARCs for younger patients who may not otherwise seek out contraceptive services (Patel 2020a). In an Oregon-based study, LARC use increased more at SBHCs receiving funding from the federal Title X Family Planning Program than at non-Title X SBHCs (Boniface 2021, Boniface 2022). The same study finds that all forms of SBHCs offered more contraceptive counseling and served more younger adolescents (ages 14 to 16) and racial or ethnic minority adolescents, compared to community health centers (Boniface 2022). An evaluation of the School-Based Health Center Reproductive Health Project in New York City suggests that offering comprehensive reproductive health services in SBHCs can increase the use of contraceptives among teens, reducing the number of teen pregnancies, teen births, and abortions, compared to teens without access to care at a SBHC (Fisher 2019).

SBHCs may increase access to reproductive health care (Ethier 2011) and prenatal care (CG-SBHC) and can reduce the likelihood of low birthweight births (CG-SBHC, Strunk 2008) among teen girls. Some SBHCs with reproductive health services may support efforts to prevent repeat pregnancies more frequently than community clinics (Strunk 2008). SBHCs also increase preventive care, including screenings for sexually transmitted infections (STIs) (Hussaini 2021). Students screened for STIs at SBHCs had a shorter time to treatment than students receiving screenings and care at offsite clinics (Sabharwal 2018). SBHC users are more likely to complete the human papillomavirus (HPV) vaccination series than those using traditional clinics (Munn 2019). In SBHCs, barriers to completing the HPV vaccine series include low appointment compliance and scheduling challenges; experts recommend using reminder systems for appointments and streamlining the parental consent process (Oliver 2019).

Ease of access (Westbrook 2022, Stein 2020, Mason-Jones 2012), low costs (Westbrook 2022, Stein 2020), and confidential services are often cited as reasons teens use SBHC services (Westbrook 2022, Keeton 2012), especially in rural areas (Westbrook 2022).

SBHCs with reproductive health services may reduce absenteeism and dropout rates among pregnant and parenting teens (Strunk 2008) but do not appear to have a significant effect on dropout rates overall (NBER-Lovenheim 2016).

School-based health centers (SBHCs) with reproductive health services have the potential to decrease disparities in access to reproductive health care when they are implemented in areas with fewer resources, including urban or rural areas with more residents with lower incomes or who are from racial and ethnic minoritized groups. Experts suggest that SBHCs with reproductive health services may be used in non-urban communities to reduce access barriers for young people to reproductive health care (Westbrook 2022). Available evidence suggests SBHCs may increase access to contraception and increase contraception use for students from socio-economically disadvantaged populations compared to students with greater socio-economic advantages (Bersamin 2018). SBHCs frequently care for adolescent populations that are more racially diverse (Gersh 2019) and can reduce birth rates among Black and Hispanic teens (NBER-Lovenheim 2016). Students who have public insurance appear to use SBHCs more frequently than their peers with private insurance (Stempel 2019). More evidence is needed to determine if SBHCs with reproductive health services can impact disparities.

Teen birth rates vary among racial, ethnic, geographic, and socioeconomic groups; for example, teen birth rates remain higher among teens from minoritized groups (Hispanic, non-Hispanic Black, American Indian, and Alaska Native) and among teens living in the Southern and Southwestern U.S. Greater understanding around community and external structural factors is needed (Fuller 2018, CDC-About teen pregnancy). Sexually transmitted infections (STIs) disproportionately affect racial and sexual minority groups (CDC-STI Surveillance). In rural areas, additional education may be needed for young people to understand their right to access contraceptive services and confidential care from SBHCs (Westbrook 2022). SBHCs located in the Northeastern or Western U.S. may be more likely to dispense contraceptives than those in other areas (Sullivan 2022).

Experts recommend SBHCs that care for Hispanic students include bilingual staff, which may support relationship building with both students and their parents and allow staff to discuss consent forms and available services with parents (Smith 2019a).

Teen pregnancy rates have been declining in the U.S. since 1991, though rates are still higher than in other high income nations, and racial and geographic disparities persist (CDC-About teen pregnancy). In rural communities, lack of sexual and reproductive health education and services increases risks for adolescent pregnancy (Ott 2020).

The first school-based health centers (SBHCs) were established in the late 1960s and early 1970s at urban schools in Cambridge, Massachusetts; St. Paul, Minnesota; and Dallas, Texas (Ryst 2021, Love 2019, Arenson 2019). Early SBHCs were primarily focused on access to family planning, teen pregnancy prevention, and support for adolescent parents still in school, through funding from the federal Title X Family Planning Program and American Academy of Pediatrics Community Access to Child Health Grants (Ryst 2021, Love 2019). In the mid-1980s, efforts to highlight rates of teenage pregnancies and prevention programs by organizations such as the Children’s Defense Fund brought additional interest and funding to SBHCs (Morone 2001). SBHCs greatly expanded in the 1990s (Arenson 2019), and Medicaid expansions made SBHCs more sustainable, providing health insurance to adolescents from families with low incomes, who previously would have been unable to afford care (Love 2019).

SBHCs became more broadly recognized as safety net health care providers for children without regular access to affordable health care (Arenson 2019) with the Patient Protection and Affordable Care Act (ACA) in 2010, which included $200 million to add or expand SBHCs in medically underserved communities and areas with a health professional shortage (Arenson 2019). Additional funding for SBHCs comes from state governments, school districts, private foundations, and partner organizations (Arenson 2019). However, SBHCs may still encounter challenges around offering sexual and reproductive health care in school, such as concerns from parents and guardians about adolescents in engaging in risk behaviors, religious leaders about birth control, and politically conservative community members and politicians (Moore 2023, Morone 2001).

• How can students and families be involved in decisions surrounding school-based health centers (SBHCs) programming and service availability, including services for reproductive health care?
• What efforts can SBHCs and partners make to develop trusting, comfortable relationships between providers and underserved students and families? Can students who have benefited from care at SBHCs partner with them on outreach efforts to the broader school community?
• What additional funding (e.g., local, state, or federal government; non-profits, private organizations) can SBHC administrators consider to expand services?
• How can SBHCs offering reproductive health services educate students about their right to access confidential care?

Many school-based health centers (SBHCs) offer reproductive health services. Services provided vary, most often including pregnancy testing; sexually transmitted infection (STI) prevention, testing, and treatment; and cervical screening for cancer, commonly known as a pap smear or pap test (SBHA-SBHC). People younger than 18 can consent to STI services in all states and Washington, D.C.; however, consent to contraceptive services is only permitted in 27 states (and D.C.), and consent to prenatal care in 33 states (and D.C.) (Guttmacher-Reproductive health consent 2023).

Many SBHCs are in bigger cities. SBHCs in New York City public schools offer reproductive health services including contraceptives, testing and treatment for STIs, pregnancy testing, counseling, and health education. Per New York State law, people younger than 18 can consent to their own care for reproductive health services, including birth control, STI testing and treatment, and prenatal care (NYC DOE-SBHC, Guttmacher-Reproductive health consent 2023). The University of New Mexico Medical Group and University of New Mexico Health (UNM) Sciences Center co-sponsor the UNM School-Based Health Center program, which cares for students across six Albuquerque schools, including reproductive and sexual health services (UNM-SBHC).

‡ Resources with a focus on equity.

CA SBHA - California School-Based Health Alliance (CA SBHA). Putting health where kids are.

Child Trends-Kim 2022 - Kim L, Cook E, Parekh J, Manlove J. Increasing access to adolescent-friendly LARC Services in school-based health centers. IN: Toolkit for Improving Family Planning Services in School Settings. Child Trends. 2022.

NYC DOE-SBHC - New York City Department of Education (NYC DOE). School-Based Health Centers (SBHC).

SBHA - School-Based Health Alliance (SBHA). Redefining health for kids and teens.

SBHA-SBHC^‡ - School-Based Health Alliance (SBHA). Findings from the 2022 national census of school-based health centers (SBHCs). 2023.

* Journal subscription may be required for access.

Arenson 2019 - Arenson M, Hudson PJ, Lee NH, Lai B. The evidence on school-based health centers: A review. Global Pediatric Health. 2019;6.

Bersamin 2018 - Bersamin M, Paschall MJ, Fisher DA. Oregon school-based health centers and sexual and contraceptive behaviors among adolescents. Journal of School Nursing. 2018;34(5):359-366.

Blank 2010* - Blank L, Baxter SK, Payne N, Guillaume LR, Pilgrim H. Systematic review and narrative synthesis of the effectiveness of contraceptive service interventions for young people, delivered in educational settings. Journal of Pediatric and Adolescent Gynecology. 2010;23(6):341-351.

Boniface 2021 - Boniface ER, Rodriguez MI, Heintzman J, et al. Contraceptive provision in Oregon school-based health centers: Method type trends and the role of Title X. Contraception. 2021;104(2):206-210.

Boniface 2022 - Boniface ER, Rodriguez MI, Heintzman J, et al. A comparison of contraceptive services for adolescents at school-based versus community health centers in Oregon. Health Services Research. 2022;57(1):145-151.

CDC-About teen pregnancy - Centers for Disease Control and Prevention (CDC). About teen pregnancy.

CDC-Contraception - Centers for Disease Control and Prevention (CDC). Contraception and birth control methods.

CDC-STI Surveillance - Centers for Disease Control and Prevention (CDC). Sexually Transmitted Infections Surveillance.

CG-SBHC - The Guide to Community Preventive Services (The Community Guide). Social determinants of health: School-based health centers (SBHCs). 2015.

Comfort 2021* - Comfort AB, Rao L, Goodman S, et al. Improving capacity at school-based health centers to offer adolescents counseling and access to comprehensive contraceptive services. Journal of Pediatric and Adolescent Gynecology. 2021;34(1):26-32.

Ethier 2011* - Ethier KA, Dittus PJ, DeRosa CJ, et al. School-based health center access, reproductive health care, and contraceptive use among sexually experienced high school students. Journal of Adolescent Health. 2011;48(6):562-565.

Fisher 2019* - Fisher R, Danza P, McCarthy J, Tiezzi L. Provision of contraception in New York City school‐based health centers: Impact on teenage pregnancy and avoided costs, 2008–2017. Perspectives on Sexual and Reproductive Health. 2019;51(4):201-209.

Fuller 2018* - Fuller TR, White CP, Chu J, et al. Social determinants and teen pregnancy prevention: Exploring the role of nontraditional partnerships. Health Promotion Practice. 2018;19(1):23-30.

Gersh 2019* - Gersh E, Arghira AC, Richardson LP, et al. Comparison of health risks among adolescents from school-based health centers and community-based primary care settings. Health Behavior and Policy Review. 2019;6(1):71-78.

Guttmacher-Reproductive health consent 2023 - Guttmacher Institute. State Laws and Policies: An overview of consent to reproductive health services by young people. New York: Guttmacher Institute; August 30, 2023.

Hussaini 2021* - Hussaini KS, Offutt-Powell T, James G, Koumans EH. Assessing the effect of school-based health centers on achievement of national performance measures. Journal of School Health. 2021;91(9):714-721.

Keeton 2012* - Keeton V, Soleimanpour S, Brindis CD. School-based health centers in an era of health care reform: Building on history. Current Problems in Pediatric and Adolescent Health Care. 2012;42(6):132-156.

Love 2019* - Love HE, Schlitt J, Soleimanpour S, Panchal N, Behr C. Twenty years of school-based health care growth and expansion. Health Affairs. 2019;38(5):755-764.

Mason-Jones 2012 - Mason-Jones AJ, Crisp C, Momberg M, et al. A systematic review of the role of school-based healthcare in adolescent sexual, reproductive, and mental health. Systematic Reviews. 2012;1:49.

Moore 2023* - Moore MJ, Barr E, Hayes C, Binder M. voter support for offering sexual health services through school-based health clinics. American Journal of Sexuality Education. 2023;18(1):24-38.

Morone 2001* - Morone JA, Kilbreth EH, Langwell KM. Back to school: A health care strategy for youth. Health Affairs. 2001;20:1:122-136.

Munn 2019 - Munn MS, Kay M, Page LC, Duchin JS. Completion of the human papillomavirus vaccination series among adolescent users and nonusers of school-based health centers. Public Health Reports. 2019;134(5):559-566.

NBER-Lovenheim 2016 - Lovenheim M, Reback R, Wedenoja L. How does access to health care affect teen fertility and high school dropout rates? Evidence from school-based health centers. National Bureau of Economic Research (NBER). 2016: Working Paper 22030.

NYC DOE-SBHC - New York City Department of Education (NYC DOE). School-Based Health Centers (SBHC).

Oliver 2019* - Oliver K, McCorkell C, Pister I, et al. Improving HPV vaccine delivery at school-based health centers. Human Vaccines and Immunotherapeutics. 2019;15(7-8):1870-1877.

Ott 2020* - Ott MA, Hunt AL, Katz AJ, Zaban LS. Tapping into community resiliency in rural adolescent pregnancy prevention: An implementation sciences approach. Behavioral Medicine. 2020;46(3-4):340-352.

Owen 2010 - Owen J, Carroll C, Cooke J, et al. School-linked sexual health services for young people (SSHYP): A survey and systematic review concerning current models, effectiveness, cost-effectiveness and research opportunities. Health Technology Assessment. 2010;14(30).

Patel 2020a* - Patel PR, Abacan AA, Al-Lami RA, Smith PB. Do school-based clinics increase access to LARC services among teenagers? Journal of Medical Discovery. 2020;5(3):1-7.

Ricketts 2006 - Ricketts SA, Guernsey BP. School-based health centers and the decline in black teen fertility during the 1990s in Denver, Colorado. American Journal of Public Health. 2006;96(9):1588-1592.

Ryst 2021 - Ryst E, Joshi S V. Collaboration with schools and school-based health centers. Child and Adolescent Psychiatric Clinics of North America. 2021;30(4):751-765.

Sabharwal 2018* - Sabharwal M, Masinter L, Weaver KN. Examining time to treatment and the role of school-based health centers in a school-based sexually transmitted infection program. Journal of School Health. 2018;88(8):590-595.

SBHA-SBHC - School-Based Health Alliance (SBHA). Findings from the 2022 national census of school-based health centers (SBHCs). 2023.

Smith 2019a* - Smith PB, Abacan AA, Chacko MR. Enhancing parent consent for school-based primary and reproductive health care among vulnerable youth. Journal of Sex and Marital Therapy. 2019;45(4):276-282.

Stein 2020* - Stein TB, Summit AK, St. Louis M, Gold M. Patient satisfaction with IUD services in a school-based health center: A pilot study. Journal of Pediatric and Adolescent Gynecology. 2020;33(4):388-392.

Stempel 2019* - Stempel H, Cox-Martin MG, O’Leary S, Stein R, Allison MA. Students seeking mental health services at school-based health centers: Characteristics and utilization patterns. Journal of School Health. 2019;89(10):839-846.

Strunk 2008* - Strunk JA. The effect of school-based health clinics on teenage pregnancy and parenting outcomes: An integrated literature review. The Journal of School Nursing. 2008;24(1):13-20.

Sullivan 2022* - Sullivan EE, Love HL, Fisher RL, et al. Access to contraceptives in school-based health centers: Progress and opportunities. American Journal of Preventive Medicine. 2022;62(3):350-359.

Summit 2019* - Summit AK, Friedman E, Stein TB, Gold M. Integration of onsite long-acting reversible contraception services into school-based health centers. Journal of School Health. 2019;89(3):226-231.

UNM-SBHC - UNM School-Based Health Center (SBHC) program. University of New Mexico Medical Group and University of New Mexico Health Sciences Center.

Westbrook 2022* - Westbrook M, Martinez L, Mechergui S, Scandlyn J, Yeatman S. Contraceptive access through school-based health centers: Perceptions of rural and suburban young people. Health Promotion Practice. 2022;23(3):425-431.