The percentage of patients assigned female at birth ages 15-44 who were asked the Self-Identified Need for Contraception (SINC) question with a recorded response, among patients with a qualifying encounter. (Contraceptive Care Screening eCQM)

Access to high quality, patient-centered contraceptive care is essential for people to achieve their reproductive goals.

Achieving individual reproductive goals depends on being able to achieve or prevent pregnancy when and how a person wants (1). In 2015, based on National Survey of Family Growth (NSFG) data, only 47.9% of pregnancies were categorized as occurring as desired at the time for the individual (2). Contraceptive technology is key for those who want to prevent pregnancy, and the most commonly used contraceptive methods in the United States require contact with a health care provider (3). Moreover, access to sexual and reproductive healthcare has been associated with use of prescription contraceptive methods and contraceptive counseling has been linked to ongoing contraceptive use (4,5).

Barriers to access to contraceptive care exist. 

Despite this need for contraceptive services, many people who do not want to become pregnant do not use contraception. Data from the NSFG, for example, found that of those at risk of an unintended pregnancy and who were sexually active, 18% were not using any form of contraception, and, of those, 84% did not want to become pregnant in the following two years (6). One contributor to these statistics is lack of access to contraceptive care. Within this analysis, among those who wanted to prevent pregnancy for at least 5 years, 19% reported that they were not using contraception because they could not access a method (6). More broadly, NSFG analyses find that only 46% of women at risk of unintended pregnancy receive contraceptive services in a year, with disparities by both race/ethnicity and age (with younger patients being less likely to receive contraceptive services) (7). Further, among ambulatory encounters with women of reproductive age in the United States, only 14% include any reproductive health services, including contraception (8). 

Gaps in care access are not equitably experienced across demographic groups. 

In one NSFG analysis of the 2006-2017 waves of data collection found that overall 18.3% of women of reproductive age received contraceptive counseling, and when looking at subgroups, found the Black and Latina heterosexual women had lower odds of receiving contraceptive counseling compared to white heterosexual women (with Latina sexual minority women having the lowest odds) (9). Additionally, changing policy environments have led to a decrease in contraceptive care access and increased barriers to care. A recent study used four waves of cross-sectional study data to look at changes in contraceptive care access in four states between 2021 and 2023 and found a four-percentage point increase in reported barriers to accessing contraceptive care between the time points (10). Moreover, ten percent of respondents who were not using a preferred contraceptive method named access barriers, including difficulty accessing a facility, as a reason (11). These barriers infringe upon individuals’ ability to access and use contraception, compromising their ability to achieve their reproductive goals. 

Screening for contraceptive need can enhance access. One evidence-based strategy to enhance the ability of those who want contraceptive care to receive it is to ensure that patients accessing care for any reason are screened for contraceptive need, with integration of proactive screening for pregnancy prevention need being promoted by the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists (12,13). This is particularly relevant in the primary care context, in which many reproductive age women receive care (14) and in which competing priorities, including preventive health screening and chronic disease management, can interfere with attention to reproductive health needs. Standardized screening for contraceptive need can aid in ensuring that individual’s reproductive health needs are being met alongside these other key health needs; implementation of standardized reproductive needs screening has been shown to increase documentation of contraceptive care screening in health center settings (15). Additionally, ensuring contraceptive care screening is incorporated into diverse healthcare settings, including primary care, could help increase access to contraceptive counseling, as reported challenges to integrating contraceptive care into primary care include lack of provider counseling initiation due to factors including assumption about patient need and interest, and relying on the patient to initiate provision (16–19). Thus, implementation of standardized screening can complement other systems-level efforts, including provider training and use of patient decision support tools, to optimize contraceptive care (20). One study showed that standardized integration of reproductive health screening in a community health center setting led to a 24% increase in clinician counseling about contraception (8), ultimately expanding access to wanted contraceptive services.

Standardized screening for desire for contraceptive care must be implemented in a patient-centered manner with attention to the history and context of contraceptive care delivery. Standardized screening approaches must be patient-centered in order to ensure they optimize patient care experience. This is particularly true in the context of reproductive health care, which encompasses sensitive services that require attention to patient comfort in discussing personal issues. Further, it is essential to recognize that the provision of contraception care services has a fraught history in the United States, marked by targeted marketing of birth control to and forced sterilization of Black and Indigenous people of color, as well as people living on low-incomes and people with disabilities, motivated by the desire to curb the reproduction of these groups (21,22). Asking about contraception and pregnancy prevention in the healthcare setting carries the weight of this history. It is therefore critical that screening for contraceptive need is done in a manner that does not inadvertently reproduce harm by communicating a sense of expectation or pressure to use pregnancy prevention methods. This is particularly critical as even in current clinical practice, Black and Latina women have been documented to be more likely to be subjected to directive, non-patient-centered contraceptive and reproductive health care services (23–27). Several evidence-informed commentaries have highlighted the ways in which structures of power in health systems and care delivery, including how we ask individuals about their pregnancy prevention needs, entrenches inequities by stigmatizing the reproduction of certain groups, such people living on low incomes and people of color, and titrating their care and de-centering their needs (1,28,29). Person-centered approaches to contraceptive care screening must therefore work to re-center individual preferences, needs and values. 

Literature on patient preferences for screening has highlighted that patients prefer to be asked about their reproductive health needs through service-bound questions. In one qualitative study, patients desired contraceptive counseling availability in primary care, provided that they engage in a manner that respects their autonomy and reproductive desires. To achieve this, they preferred a contraceptive care screening question that was open-ended, inclusive, and promoted autonomy, with a preference for a service-bound question akin to SINC (30). This finding was further tested and reinforced in a survey of over 1,000 federally qualified health center patients in New York (31).

The SINC screening question is therefore an evidence-based, person-centered approach to screening for contraceptive need. The SINC screening question was developed in response to this evidence for patient-centered approaches to screening and consists of a standardized question and response options in the LOINC code system.  Developed through our engagement with Reproductive Justice consultants and industry stakeholders, this screening question asks patients for their desire for contraceptive services on the day of their visit. Building on the literature assessing how patients want to be asked about their reproductive needs, SINC takes a person-centered, service-bound approach that does not rely on assumptions about why patients are seeking contraception (28). SINC is aligned with the increasing attention to the need for respectful reproductive care by focusing on patients’ own assessment of their pregnancy prevention needs instead of basing assessment of contraceptive on assumptions about when and how people should become pregnant or use contraception. A standardized measure of self-identified contraceptive need provides an opportunity to hardwire patient-centered and reproductive autonomy focused workflows into the EHR that can facilitate patients getting their needs met.  Throughout the development of this question and the response options, attention was paid to ensure that people’s own preferences and needs related to reproduction are recognized and respected. For example, by initiating the screening with a reference to the standardized nature of the question, we sought to prevent any perceived or real targeting of the reproductive choices of certain individuals or individuals from certain groups. We also carefully considered the ordering of the answer options so as not to infer that the most or only acceptable response was “I am already using contraception”. Implementation of this screening is designed to support reproductive autonomy and patient privacy, as well as decrease inequities in the provision of contraception services. For this reason, guidance is to ask patients of reproductive age SINC annually, creating access opportunity without undue pressure. Guidance also includes asking SINC to current prescription contraceptive users, recognizing that these individuals may want to switch or discontinue methods and should be provided with opportunity to discuss their contraceptive needs. Service-bound screening through the use of SINC therefore helps center patients in their own decision at the time of visit and enables them to meet their long-term reproductive goals, including using pregnancy prevention when desired, while protecting against provider and health system bias.

We emphasize that we have intentionally defined the specifications for this measure to be aligned with principles of patient-centeredness, as delineated in Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs. (32). First, we have included patients who are currently using methods, as current users should still be screened annually, as they may be interested in changing or stopping methods or have questions about their method. This is particularly salient for individuals using long-acting reversible contraceptive (LARC), where removal is provider-dependent. The measure excludes individuals who receive prenatal care for a pregnancy that would make them eligible for postpartum contraception during the measurement period. Individuals who receive peripartum care have reproductive health needs that are distinct and temporally bound to the timing of their pregnancy and delivery (e.g., most pregnant individuals receive contraceptive counseling at visits occurring between 24 and 32 weeks of their pregnancy). Screening for contraceptive need during and directly following pregnancy is already well-incorporated into workflows and systems of care. One PRAMS assessment found that majority of women received prenatal (78%) and postpartum (86%) contraceptive counseling; 72% received both (33). As a result, the quality gap is not whether individuals are being screened for contraceptive need, but rather the quality of the contraceptive counseling itself. Therefore, standardized screening through SINC does not address a gap in care for these individuals. Utilizing SINC in place of current planning-based screening tools common in peripartum contraceptive counseling would increase the person-centeredness of screening and be aligned with reproductive autonomy, but requiring reporting of SINC in this time period has the potential to communicate undue pressure on the individual in the peripartum period, particularly among those who already formulated decisions early in pregnancy about their postpartum contraceptive use.

Before SINC no measure of patient desire for contraceptive services existed for consistent implementation across electronic health record (EHR) systems (note that One Key Question® (34), a proprietary question that assess desire for pregnancy in the next year, does not fulfill this need, in that it assesses future desires, rather than immediate need for services). Alternative approaches commonly used in assessing for contraceptive need use indirect methods of assessment, such as asking about future pregnancy desires. We recently published an evidence-informed commentary in Contraception that highlights that this approach is not patient-centered and does not reflect how many people think about pregnancy and pregnancy prevention. Namely, a pregnancy intention-based approach ignores the complexity of lived experience and feelings toward pregnancy and pregnancy prevention (28). Additionally, two studies tested one such approach, One Key Question®, alongside a measure of current desire for pregnancy prevention. These studies found that desire for future pregnancy or ambivalence about future pregnancy and desire for pregnancy prevention now were not always aligned – a sizable minority of those surveyed who wanted pregnancy in the next year wanted to prevent pregnancy now (35,36). Pragmatically that means that if employed as a screening tool, this or similar screening approaches will miss individuals who desire contraceptive services. 

Measurement of SINC utilization will identify gaps in meeting patient needs and serve as the basis for quality improvement to enhance contraceptive care provision. Multiple commentaries have detailed how the use of performance measures related to contraceptive provision can improve the quality of contraceptive care and promote positive reproductive health outcomes (37–39). A measure of contraceptive screening is an essential addition to the ecosystem of contraceptive measures, providing a critical step in the pathway to contraceptive provision and use, as currently measured in CBE #2902, #2903, #2904, #3699e, and #3682e. Having SINC as the basis of this screening measures aligns with quality as defined by National Academy of Medicine (40) and is an effective and patient-centered approach to identifying those with a contraceptive need that is responsive to individual perspectives on reproduction and the history of harm enacted in the reproductive health care delivery system. The promise of this measure was recently emphasized in the CMS bulletin on family planning services, which stated that states could consider including SINC in their standard data collection to assess whether individuals are receiving respectful care and the family planning services and supplies they need (41). In addition, earlier this year the Human Resources and Services Administration (HRSA) announced a new requirement for federally qualified health centers to report the number of patients screened for contraception need using a standardized screening instrument (31). HRSA named SINC explicitly as an instrument to use to meet this requirement. The Office of Population Affairs also included SINC as an optional reporting element in FPAR 2.0 (data element 41) (32).

We emphasize that we have intentionally defined the specifications for this measure to be aligned with principles of patient-centeredness, as delineated in Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs. (32). First, we have included patients who are currently using methods, as current users should still be screened annually, as they may be interested in changing or stopping methods or have questions about their method. This is particularly salient for individuals using long-acting reversible contraceptive (LARC), where removal is provider-dependent. The measure excludes individuals who receive prenatal care for a pregnancy that would make them eligible for postpartum contraception during the measurement period. Individuals who receive peripartum care have reproductive health needs that are distinct and temporally bound to the timing of their pregnancy and delivery (e.g., most pregnant individuals receive contraceptive counseling at visits occurring between 24 and 32 weeks of their pregnancy). Screening for contraceptive need during and directly following pregnancy is already well-incorporated into workflows and systems of care. One PRAMS assessment found that majority of women received prenatal (78%) and postpartum (86%) contraceptive counseling; 72% received both (33). As a result, the quality gap is not whether individuals are being screened for contraceptive need, but rather the quality of the contraceptive counseling itself. Therefore, standardized screening through SINC does not address a gap in care for these individuals. Utilizing SINC in place of current planning-based screening tools common in peripartum contraceptive counseling would increase the person-centeredness of screening and be aligned with reproductive autonomy, but requiring reporting of SINC in this time period has the potential to communicate undue pressure on the individual in the peripartum period, particularly among those who already formulated decisions early in pregnancy about their postpartum contraceptive use.

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