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Abstract

PURPOSE: The purpose of this study was to assess the impact of different policies on access to hormonal contraception and pregnancy rates at two high school-based clinics.

METHODS: Two clinics in high schools (Schools A and B), located in a large urban district in the southwest US, provide primary medical care to enrolled students with parental consent; the majority of whom have no health insurance coverage. The hormonal contraceptive dispensing policy of at School clinic A involves providing barrier, hormonal and emergency contraceptive services on site. School clinic B uses a referral policy that directs students to obtain contraception at an off-campus affiliated family planning clinic.

Baseline data (age, race and history of prior pregnancy) on female students seeking hormonal contraception at the two clinics between 9/2008-12/2009 were extracted from an electronic administrative database (AHLERS Integrated System). Data on birth control use and pregnancy tests for each student was then tracked electronically through 3/31/2010. The outcomes measures were accessing hormonal contraception and positive pregnancy tests at any point during or after birth control use were started through 12/2009. The appointment keeping rate for contraceptive services and the overall pregnancy rates were compared between the two schools. In addition the pregnancy rates were compared between the two schools for students with and without a prior history of pregnancy.

RESULTS: School clinic A: 79 students sought hormonal contraception; mean age 17.5 years; 68% were > 18 years; 77% were Hispanic; and 20% reported prior pregnancy. The mean duration of the observation period was 13 months (4-19 months). All 79 students received hormonal contraception (65% pill and 35% long acting progestin injection) onsite. During the observation period, the overall pregnancy rate was 6% (5/79); 4.7% (3/63) among students with no prior pregnancy. School clinic B: 40 students sought hormonal contraception; mean age 17.5 years; 52% > 18 years; 88 % were Hispanic; and 7.5% reported prior pregnancy. All 40 students were referred to the affiliated clinic. The mean duration of the observation period was 11.9 months (4-19 months). 50% (20) kept their appointment. Pills were dispensed to 85% (17/20) and 15% (3/20) received long acting progestin injection. The overall pregnancy rate was 20% (8/40); 21.6% (8/37) among students with no prior pregnancy.

A significantly higher frequency of students seeking hormonal contraception kept their initial appointment for birth control at the school dispensing onsite contraception compared to the school with a referral policy for contraception (p<0.05). The pregnancy rate was significantly higher for the school with a referral policy for contraception compared to the school with onsite contraceptive services (p< 0.05). The pregnancy rate was also significantly higher for students without a prior history of pregnancy in the school with a referral policy for contraception (21.6%) versus the school with onsite contraceptive services (4.7%) (p< 0.05).

CONCLUSION: This preliminary study showed that School clinic B with a referral policy had a lower appointment keeping rate for contraceptive services and a higher pregnancy rate than School clinic A with on-site contraceptive services. An on-site dispensing policy for hormonal contraceptives at high school-based health clinics may be a convenient and effective approach to prevent unintended first and repeat pregnancies among adolescents who seek hormonal contraception. This study has strong implications for reproductive health policy, especially as directed toward high-risk teenage populations.

Key Take Away Points

  • On-site school-based health clinic dispensing hormonal contraception has a lower pregnancy rate than the school-based health clinic referring female students for hormonal contraception.

Author Biography

Peggy B. Smith, Ph.D., is a Professor in the Departments of Obstetrics and Gynecology, Psychology, and Pediatrics, Baylor College of medicine. As the Director of the Teen Health Clinic, she is responsible for overall direction, evaluation, and funding of this county-wide system of 7 comprehensive reproductive health programs for indigent teens. Dr. Smith has published over 130 articles on teenage sexuality and pregnancy and has published 3 books on adolescent pregnancy and reproductive health. She has served as Chair of the Children’s Trust Fund, an American Leadership Forum fellow, and was appointed to serve on a number of state health committees. She is currently on the board for the Children’s Defense Fund and Episcopal Health Charities. Dr. Smith received a B.A. in Psychology, a M.A. in Special Education and a Ph.D. in Education from the University of Texas at Austin.

Gabrielle D. Novello, B.A., is a Research Assistant with the Baylor Teen Health Clinic. For the past two years, Ms. Novello has provided academic support in areas of qualitative and quantitative analysis and assessment. She has provided research assistance for a variety of publication submissions and grant proposals, and has aided in updating annual reports and evaluations, as well as organizing supporting clinic documents. She has been dedicated to adolescent, reproductive and minority health and will be expanding her understanding of these foci internationally as an intern with the U.S. Agency for International Development in Ethiopia during the summer of 2011. Concurrently, Ms. Novello is pursuing her Master’s in Public Health from the University of Texas School of Public Health at the Health Science Center in Houston in Management, Policy and Community Health, and received her Bachelor’s of Arts from Rice University in Houston, Texas in 2009.

Mariam R. Chacko, M.D. is Professor of Pediatrics in the Section of Adolescent & Sports Medicine, Baylor College of Medicine. She is also Medical Director of the Baylor Teen Health Clinic which includes family planning and school-based clinics. She received her M.B.B.S. degree at Christian Medical College, University of Punjab, India; pediatric residency training at Baltimore City Hospitals, Johns Hopkins University and adolescent medicine fellowship training at the University of Maryland Hospital in Baltimore. She is board certified in Pediatrics and in Adolescent Medicine. She provides clinical services to young people in a variety of settings and teaches adolescent medicine to medical students, residents and fellows. Dr. Chacko also conducts clinical research in reproductive health issues in adolescent and young adult women.

Acknowledgements

Acknowledgments: This article was supported in part by a grant from St. Luke’s Episcopal Health Charities, the Simmons Foundation and Maternal Child Health Bureau/Leadership Education in Adolescent Health Grant - 2 T71 MC00011

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Responses to this Article:

Laura Davis and Emily Bridges, School Based Health Centers Should Provide Contraception to Teens (October 2011)