School-based health centers with reproductive health services
School-based health centers (SBHCs) provide a variety of health care services to students. Many middle and high school-based clinics offer reproductive services, which generally include abstinence and contraception counseling, pregnancy and sexually transmitted infections (STIs) testing, and may also include distributing contraceptives. Some clinics offer prenatal care1. SBHCs are most frequently located in urban and rural neighborhoods with residents of lower socio-economic status2, 3; in 2022, about 70% of students attending schools with SBHCs were racial or ethnic minorities4.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Increased use of contraception
Reduced low birthweight births
Reduced teen births
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Increased reproductive health care
Reduced teen pregnancy
Increased preventive care
Improved student attendance
Increased high school completion
Increased vaccination
Increased STI testing
What does the research say about effectiveness?
There is some evidence that school-based health centers (SBHCs) that provide reproductive health services increase contraceptive use5, particularly among teenaged girls3, 6, 7, 8; reduce teen birth rates2, 9, 10, especially among Black and Hispanic youth2; and reduce the likelihood of low birthweight births1, 3. 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 not5, 11. More SBHCs are providing long-acting reversible contraceptives (LARCs) as part of their reproductive health services6; LARCs include intrauterine devices (IUDs) and contraceptive implants12. Students appear to find SBHCs’ provision of IUDs acceptable and be satisfied with their care13. Additional contraceptive training for SBHC providers appears to increase the use of LARCs14, 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 SBHCs15. A Texas-based study suggests that SBHCs may increase access to LARCs for younger patients who may not otherwise seek out contraceptive services16. 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 SBHCs6.
SBHCs may increase access to reproductive health care8 and prenatal care3 among teen girls. Some SBHCs with reproductive health services may support efforts to prevent repeat pregnancies more frequently than community clinics1. SBHCs also increase preventive care, including screenings for sexually transmitted infections (STIs)17. Students screened for STIs at SBHCs had a shorter time to treatment than students receiving screenings and care at offsite clinics18. SBHC users are more likely to complete the human papillomavirus (HPV) vaccination series than those using traditional clinics19. 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 process20.
Ease of access13, 21, 22, low costs13, 21, and confidential services are often cited as reasons teens use SBHC services7, 21, especially in rural areas21.
SBHCs with reproductive health services may reduce absenteeism and dropout rates among pregnant and parenting teens1 but do not appear to have a significant effect on dropout rates overall2.
How could this strategy advance health equity? This strategy is rated potential to decrease disparities: suggested by expert opinion.
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 greater needs, including urban or rural areas with residents with low incomes and those with larger populations of racial or ethnic minorities. 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 care21. 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 advantages5. SBHCs frequently care for adolescent populations that are more racially diverse25 and can reduce birth rates among Black and Hispanic teens2. Children that are uninsured may be more likely to have a SBHC as their primary source of health care26 and students who have public insurance appear to use SBHCs more frequently than their peers with private insurance27. More evidence is needed to determine if they can impact disparities.
Birth rates remain high for young women of color28, 29; American Indian and Alaska Native teens have the highest birth rates, and Hispanic and Black teens’ birth rates are two times higher than that of white teens29. Sexually transmitted infections (STIs) disproportionally affect racial and sexual minority groups30. In rural areas, additional education may be needed for young people to understand their right to access contraceptive services and confidential care from SBHCs21. SBHCs located in the Northeastern or Western portions of the U.S. may be more likely to dispense contraceptives than those in other areas31.
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 parents32.
What is the relevant historical background?
Teen pregnancy rates have been declining in the U.S. since 199133; however, rates are still higher than in other industrialized nations, and racial and geographic disparities exist within the country29. In rural communities, lack of sexual and reproductive health education and services increases risks for adolescent pregnancy34.
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, Texas35, 36, 37. 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 Grants35, 36. 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 SBHCs38. SBHCs greatly expanded in the 1990s37, 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 care36.
SBHCs became more broadly recognized as safety net health care providers for children without regular access to affordable health care37 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 shortage37. Additional funding for SBHCs comes from state governments, school districts, private foundations, and partner organizations37. However, SBHCs may still encounter challenges around offering sexual and reproductive health care in school, such as concerns from parents and guardians about promiscuity, religious leaders about birth control, and conservative community members and politicians regarding family values38.
Equity Considerations
- 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?
Implementation Examples
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 pap tests4.
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, minors can consent to their own care for reproductive health services, including birth control, STI testing and treatment, and prenatal care23. 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 services24.
Implementation Resources
‡ Resources with a focus on equity.
CA SBHA - California School-Based Health Alliance (CA SBHA). Putting health where kids are.
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.
Footnotes
* Journal subscription may be required for access.
1 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.
2 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.
3 CG-SBHC - The Guide to Community Preventive Services (The Community Guide). Social determinants of health: School-based health centers (SBHCs). 2015.
4 SBHA-SBHC - School-Based Health Alliance (SBHA). Findings from the 2022 national census of school-based health centers (SBHCs). 2023.
5 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.
6 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.
7 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.
8 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.
9 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).
10 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.
11 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.
12 CDC-Contraception - Centers for Disease Control and Prevention (CDC). Reproductive Health: Contraception.
13 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.
14 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.
15 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.
16 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.
17 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.
18 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.
19 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.
20 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.
21 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.
22 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.
23 NYC DOE-SBHC - New York City Department of Education (NYC DOE). School-Based Health Centers (SBHC).
24 UNM-SBHC - UNM School-Based Health Center (SBHC) program. University of New Mexico Medical Group and University of New Mexico Health Sciences Center.
25 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.
26 Habiyaremye 2021 - Habiyaremye MA, Clary K, Morris H, Tumin D, Crotty J. Which children use school-based health services as a primary source of care? Journal of School Health. 2021;91(11):876-882.
27 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.
28 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.
29 CDC-About teen pregnancy - Centers for Disease Control and Prevention (CDC). About teen pregnancy.
30 CDC-STD 2021 - Centers for Disease Control and Prevention (CDC). Sexually Transmitted Disease Surveillance 2021.
31 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.
32 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.
33 CDC-Teen pregnancy - Centers for Disease Control and Prevention (CDC). Reproductive health: Teen pregnancy.
34 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.
35 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.
36 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.
37 Arenson 2019 - Arenson M, Hudson PJ, Lee NH, Lai B. The evidence on school-based health centers: A review. Global Pediatric Health. 2019;6.
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.
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