The results of two recent studies suggest benefits for adolescents who receive contraceptive services through school-based health centers in Oregon. Contraceptive Technology Update asked lead author Emily R. Boniface, MPH, research associate in Oregon Health and Science University’s department of obstetrics and gynecology, to answer questions about the new research. The transcript has been lightly edited for length and clarity.
CTU: One study finding is that school-based health centers provided both more counseling and showed a larger increase in long-acting reversible contraceptive (LARC) provision when compared with community health centers (CHCs).1 Why might school-based health centers (SBHCs) have had better outcomes? Are SBHCs at high schools, colleges, or both?
Boniface: The SBHCs in our sample did not include any clinics located in colleges. Our study sample only included SBHC visits that served adolescents aged 14-19.1
Our finding that SBHCs provided more counseling may be a result of a few things. First, some SBHCs in Oregon are prohibited from dispensing contraception, so those counseling-only visits may be to provide counseling and a referral to another provider to get the actual method. Second, CHC providers might not bill for counseling even if they provide it, so it might not show up on the electronic health record. Third, it’s also possible that SBHCs are a more accessible source of contraceptive counseling for adolescents, considering the additional barriers they face to access care, including transportation and cost. Unfortunately, our electronic health record data only capture services that providers billed for, so we can’t definitively explain the difference.
The faster increase in LARC provision at SBHCs is likely due to the fact that SBHCs were slower to offer LARC methods than CHCs. LARC methods aren’t right for everybody, but as more SBHCs started to offer them over time, we saw more adolescents choosing those methods. The time trends in LARC provision that we observed appeared to be converging, which suggests that interest in using those methods is fairly similar at both SBHCs and CHCs.
CTU: What role did Title X play for SBHCs?
Boniface: Title X participation improved access to LARC methods at SBHCs. To participate in Title X, clinics are required to offer a wide range of contraceptive methods on-site, so it’s not surprising that we saw a big difference in provision of the most effective methods at SBHCs based on Title X participation.
CTU: In the second study, you concluded that SBHCs play an important role in providing access to contraceptive services to adolescents.2 What kind of reproductive health model do Oregon SBHCs employ, and how have these evolved over time?
Boniface: The state SBHC program’s model is based on high-quality, patient-centered, and evidence-based reproductive healthcare, and encourages on-site access to contraception as a clinical best practice. If an SBHC decides not to offer methods in the clinic, they are required to provide referrals to a provider who will dispense contraception.
Preventing adolescent pregnancy has always been a goal of Oregon’s SBHCs, from the inception of the program in 1985. Since that time, the state health authority has continued to expand the number of SBHCs. Now, there are almost 80 certified sites across the state.
CTU: The study shows that provision of intrauterine devices (IUDs) and implants increased almost fivefold at SBHCs between 2012 and 2016.2 Did this mirror the national trends in greater acceptance of IUDs and implants, or does the increase suggest something particular about SBHCs and their contraceptive counseling strategies?
Boniface: The time trends in LARC use that we observed do mirror national trends during the same period. These trends are likely caused by increased availability and endorsement of LARC methods as safe and effective for adolescents by organizations — such as the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics — instead of specific counseling strategies, which should focus on the patient’s needs and preferences rather than method effectiveness alone.
CTU: What are some advantages for SBHCs when they enroll in Title X? Is this a model that other states employ, or could it be duplicated elsewhere?
Boniface: Participating in Title X provides multiple advantages to both the clinic and its clients, including access to a wider range of methods and ongoing provider training. Since Title X is a federal program, the model could be duplicated in any state in the country, and Oregon can serve as a model for how Title X and SBHCs can work together synergistically to improve contraceptive services for adolescents. More than half of SBHCs in the country are not allowed to dispense contraception, so there is certainly room for expansion of this model nationwide.
Title X expands access to a wide range of methods in SBHCs and other participating clinics. It is encouraging news that the Biden administration recently strengthened Title X by reversing previous negative changes to the program.
- 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 Serv Res 2021 Oct 8. doi: 10.1111/1475-6773.13889. [Online ahead of print].
- 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;104:206-210.