Health care systems and providers play a critical role in supporting patient’s reproductive goals and optimizing their reproductive health. However, competing priorities in healthcare can make it difficult to identify and address patients’ reproductive health needs, particularly in primary care settings. Using a screening tool can help detect these needs and close gaps in care. Unfortunately, many screening questions related to reproductive health, like One Key Question (OKQ) or the Pregnancy Intention Screening Question (PISQ), funnel all reproductive health needs through a single question about pregnancy intention.

This focus on future pregnancy intention is not optimal for assessing need for contraceptive services since it does not capture the immediate needs of individuals, as people who may desire pregnancy in the next year may also desire pregnancy prevention now. In addition, we know that pregnancy intention is not a concept that is universally salient or relevant, and that patients in fact prefer to be asked about which services they want at the time of their visit.[1] Further, patients may want to use contraception for many reasons besides pregnancy prevention, including acne treatment, period pain management, cycle regulation, and gender affirmation.  

The Self-Identified Need for Contraception (SINC) screening question was created to give providers an easy-to-use, patient-centered reproductive health screening tool that reflects patients’ feedback and centers their reproductive autonomy while assessing their needs for contraceptive care. 

This implementation guide was created to help all types of medical professionals learn how to use SINC. Additional resources are provided in the appendix to help facilitate conversations about SINC with clinic administrators, create workflows for your health center, and support family planning policies. Any resources provided may be used without permission of UCSF to support your implementation of SINC; for technical assistance requests and inquiries on use, please reach out to [email protected].

The SINC screening question is a single-question reproductive health needs screening tool, using a service-needs approach. This tool was developed by Dr. Christine Dehlendorf and the team at the Person-Centered Reproductive Health Program (PCRHP) at the University of California, San Francisco. SINC, shown below, asks patients what reproductive health services they are interested in at the time of their appointment. There are several answer options that can help providers in documenting health needs.

We ask everyone about their reproductive health needs. Do you want to talk about contraception or pregnancy prevention during your visit today?

If yes:

Mark yes and ensure appropriate counseling is provided

If no:

Clarification Prompt: "There are a lot of reasons why a person wouldn't want to talk about this, and you don't have to share anything you don't want to. Do any of these apply to you?" (mark all that apply)

• I’m here for something else
• This question does not apply to me
• I prefer not to answer
• I am already using contraception (and what)
• I am unsure or don’t want to use contraception
• I am hoping to become pregnant in the near future

The phrasing and format of these questions were developed with attention to the long history of reproductive oppression in the United States. From the forced sterilization of Black and Indigenous people of color, to the fervor and explicit promotion of long-acting reversible contraception (LARC) as a “solution” to poverty by public health professionals, we know patients’ desires and wellbeing have not always been at the center of healthcare.[1]  Patients have been pressured into making reproductive health decisions that don’t reflect their own desires, particularly for Black, Indigenous, and people of color (BIPOC). Every day, patients bring this history and their lived experiences of reproductive oppression into the exam room.

In developing this question, we were intentional in having the explicit goal to center patients’ desires and meet their needs. To meet this goal, our team collaborated with reproductive justice experts, Drs. Joia Crear-Perry and Jamila Perritt, to ensure this screening tool centers patients’ autonomy and reproductive health needs and does not replicate systems of oppression.

SINC can also be used in conjunction with electronic clinical quality measures (eCQMs) of contraceptive use to help providers understand how often they are providing contraception to patients who are interested in talking about contraception at their visits. This measure is calculated using standardized data elements in electronic health records (EHR).

Frequency

Providers should ask the SINC question at least once per calendar year. It is important to balance the frequency of the ask, as we want to avoid putting pressure on patients’ reproductive choices, with ensuring that patients’ needs are being met. Providers may also directly ask patients how frequently they would like to be asked, if at all.

SINC can be programmed into your EHR, with options to trigger a repeat ask, based on patient responses. For example, if a patient responds, “I am here for something else”, SINC can be prompted for the patient’s next visit.

For some patients, SINC is not relevant to their care, and they won’t want to be asked ever again – that’s ok! We suggest building in a way to flag if patients do not wish to be asked this question in the future. This will help the clinic respect patient preferences about this question. There are many reasons why someone would not want to be asked this question in future visits – perhaps they get their care elsewhere, or they’ve had a hysterectomy, or they do not have sex with someone who produces sperm, or they simply do not want to be asked. Any patient can be asked directly about their preferences around this.

Here are some ways staff can elicit patient preferences:

• “Would you like us to check in with you again next time you come in?”
• “How often would you like us to check in with you about this?” (options will depend on how it is programmed in the EHR)

Peripartum patients

SINC can and should be asked of patients in the peripartum period (i.e. the time immediately before and after a patient gives birth). Providers frequently make assumptions that people should want to use contraception after giving birth, as opposed to centering patient’s own needs and preferences. Asking SINC can help providers identify patients’ desires and provide appropriate counseling and support.

Given the existing standard of care to providing contraceptive counseling in the third trimester of pregnancy, it may be most useful to link SINC to that period, as well as in the postpartum period. SINC can also be integrated into existing prenatal care templates.

Gender

At its core, SINC is a gender-neutral screening question. While it was initially directed towards patients with capacity for pregnancy, SINC can be applicable for patients of any gender and anatomy. If a patient reports that SINC feels incongruous with their gender identity and they do not wish to be asked, the EHR can be programmed to cease prompting for SINC. 

It is important to reiterate that the purpose of asking SINC is NOT to get more people to use birth control. Rather, the purpose is to find out if a person wants contraception during their visit, in order to be able to meet their needs. On a clinic level, this question assesses whether  patients’ needs related to  contraception are being met.

It is also critical that clinics have the processes, resources and willingness to follow through with meeting the patient's needs – whether those needs include wanting to talk about contraception or not wanting to talk about reproductive health during their visit. We recommend that clinics consider building in clinical decision supports for various answer options. For instance, if someone indicates that they are interested in pregnancy in the near future, EHRs can remind providers to discuss whether they have any needs related to fertility and/or achieving a healthy pregnancy.

Guidance for thinking about how to optimally respond to different answers are provided below.

If someone says yes (they do want to talk about contraception:

• Mark yes. Let their provider know that they would like to talk about contraception.

If someone says no:

• There are a lot of reasons not listed here why someone would not want to share this information or talk about contraception. If someone offers a reason why they don’t want or need these services that is not listed below, the person asking the question can mark the option closest to what they say.
• If someone does not offer a reason with their response, we suggest saying the “clarification prompt” and reading them the response options.
• It is important not to pressure people for information they don’t want to share. Questions about contraception and pregnancy prevention can intentionally or unintentionally communicate judgments of patients’ reproductive decision-making and preferences. We included a list of reasons why people might not want to talk about these topics in an effort to suggest ways to communicate in a manner that minimizes real or perceived judgment by creating space for people to express the nuances of their lives. Just asking “Why?” puts pressure on people to answer a certain way or feel like they need to explain themselves. Reading the prompt and response options is a way to find out if they are already using a method while leaving space for people to opt out of answering.

Suggestions for following up on specific responses: