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The student comes in for a pregnancy test — the second time she's asked for one in matter of weeks.
She's 15. She lives with her boyfriend. He wants kids — he won't use protection. She loves him, she says. But she doesn't want to get pregnant. She knows how much harder it would be for her to finish high school.
At many schools, she would have gotten little more than some advice from a school nurse. But here at Anacostia High School in Washington, D.C., she gets a dose of midwife Loral Patchen.
Patchen asks her bluntly, what is she going to do about it? Because one of these days, the test is going to show a positive.
Patchen talks her through a range of birth control methods. There's a shot you take every few months, an IUD, or a small implant that goes into your arm, which can prevent pregnancy for years. And, of course there are birth control pills. The student opts for pills, and leaves Patchen's office with a one-month supply with a standing order for refills through the school clinic.
The hope is that this interaction will mean one fewer teen pregnancy in the city. In the Washington D.C. neighborhood where this student lives, her chance of getting pregnant is nearly three times the national average.
While U.S. teen pregnancy rates overall have trended steadily downward in the last decade, they remain high in some communities. The rates for black and Latina teens is around twice that of whites, and kids from low-income families tend to have higher rates.
Anacostia High's school midwife program is a novel approach that's showing promise in tackling the problem.
Patchen had been trying to combat the city's teen pregnancy rates for twenty years as the founder of the Teen Alliance for Prepared Parenting or TAPP at Medstar Washington Hospital Center. She was happy with what they accomplished, but she wanted more access to the young people who needed her. Her organization got a 2015 grant from the CareFirst BlueCross BlueShield health insurance to start working in two schools. Now she says she's one of a handful of school midwives in the country.
"It's much better to go where the need is rather than to sit back and wait for the need to come to you," she says.
And her role goes beyond providing prenatal care for the five to eight pregnant students who get care in the school clinic each year. Being at the school gives her a chance to help prevent pregnancies in the first place. "I wouldn't have seen these youth in any other setting — not easily, anyway," she says.
As the school midwife, Patchen can be an informal — and reliable — resource for students' questions about sex and contraception and relationships.
"I love it when I'm walking in or in the hall during lunch because I see people and they recognize me," Patchen says. "And they come in to ask me a question and they've got their two girlfriends with them. And we'll talk about condom use or a side effect of a particular method or they'll say 'I heard...'"
If she were in a hospital, only seeing young people after they're pregnant, she would never get this kind of interaction, Patchen says. Plus, the information she gives them spreads through their circle of friends.
At the school, Patchen keeps her schedule flexible to leave room for informal interactions and walk-in appointments, alongside her regular appointments with students.
When a student comes in, Patchen can can offer counseling and immediate options. If a student decides she wants an IUD, Patchen can insert it on the spot. She can prescribe birth control pills and then hand the student a packet.
The Carefirst grant pays for the services and any contraception the students request, so students don't have to rely on insurance to cover them.
"I feel really good about the fact that we offer the full range of options and we have very very low removal rates," Patchen says. She says that she talks students through the different methods and their adverse effects, and leaves the decision about which — if any --method they want to use. "And if the decision is 'yes,' it's a very informed and well grounded decision," she says.
In the three years that she's been working out of Anacostia High School, Patchen says no students participating in the program have had a subsequent pregnancy. And after choosing a long term birth control method like an IUD, 85 percent of Anacostia students are still using it one year later.
Patchen can also test for STDs, including doing rapid HIV tests in the school clinic's lab.
Just as critical, she says, is the ability to spend time talking with students about their lives-- from deciding not to have sex, to navigating relationships.
For instance, she asks: "'Who makes a good girlfriend or a boyfriend? What is that kind of person? How do you make decisions together? What do you do when you have conflict?'"
The other part of Patchen's job is on-site prenatal care for students who do get pregnant.
Last year, one of those students was Kiera — we're using students' first names only to protect their privacy. When Kiera got pregnant, she was 15 years old, and scared.
"When I met Loral and she started taking care of me in my pregnancy, she made me feel happier about being a parent," Kiera says. "She helped me out a lot."
Patchen says being in the school made it easy for Kiera to come in many times throughout her pregnancy, and talk about things like getting a required blood glucose test, or the benefits of breastfeeding — and also about her relationship with the baby's father, D'Monte.
Since D'Monte is a student at the school too, Patchen could talk to them about parenting together. And even since Kiera and D'Monte broke up — Patchen still helps them figure out how to maintain a relationship so their daughter will have two parents.
Patchen was there, along with D'monte and Kiera's mother, when Kiera gave birth to her daughter last January.
"All I saw was excitement on [Patchen's] face," D'monte recalls. "She was just so excited and she was so proud. So I couldn't let her down."
The baby is now a toddling one-year-old who goes to the daycare on site at the high school. Kiera can bring her by the school clinic whenever she needs a visit with the pediatrician, or just to say hi.
"I love it when they come to the office because her daughter is laughing and she's responsive to things and they're responsive to her. And it's a beautiful thing," Patchen says.
The fact that this is a happy, communicative family is not an accident, Patchen says. There were times of frustration, times of disagreement — it could have gone badly. But everyone — the TAPP team, the school clinic staff, and the student parents — put in a lot of hard work to do the best they could by this child.
Midwife Loral Patchen wants to be clear: she is by no means saying that teen pregnancy is a great thing. But she feels strongly that once a student is pregnant she needs real, steady support.
"Youth that are pregnant, they are very aware of all the judgement, the assumption they will fail: 'You won't be able to. Now you can't.'" Patchen says. "It's our mandate to make sure they still see themselves as having a future and an opportunity. And that means not buying into the fact that they will fail with the next sixty years of their lives."
She says a lot of people tell her her job sounds "dire" — working with young people facing the challenge of dealing with parenthood and high school at the same time. She says that's not her experience.
"My day at the school health center is the highlight of my week," Patchen says. "I see young people be brave every single day that I show up there. And I see people willing to figure out how to do really hard things. What's better than that?"
She wants more — more days in the school clinic, more schools in the program, more staff — to meet the need she sees every day she's there. She thinks this is one of the few interventions that could have a direct impact on bringing down the high rate of teen pregnancy for these young women in the District.
This story is part of a reporting partnership with NPR and Kaiser Health News.
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