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Inequality in preconception care utilization based on the opportunity inequality framework: evidence from explained
Xiaodong Wu1, Hai Fang2,3, Tingting Xu1
1School of Public Health, Capital Medical University, Beijing, China.
Frontiers in Public Health
|May 25, 2026
Summary
Preconception care (PCC) utilization in China is unequal, with individual factors like pregnancy intention playing a large role. However, structural barriers significantly impact access, especially for unplanned pregnancies, necessitating integrated strategies for equity.
Area of Science:
- Maternal Health
- Public Health Policy
- Health Equity
Background:
- Despite universal free preconception care (PCC) in China, significant utilization disparities persist.
- Understanding the balance between structural barriers and individual factors is crucial for equitable maternal health policy.
- Existing research lacks clarity on the precise contribution of structural versus individual factors to PCC utilization gaps.
Purpose of the Study:
- To quantify the relative contributions of individual 'effort' and structural 'circumstance' factors to preconception care utilization in China.
- To identify key predictors of PCC uptake and analyze disparities across different demographic and socioeconomic subgroups.
- To inform the development of targeted interventions for improving equitable access to maternal health services.
Main Methods:
- A multi-center cross-sectional survey of 8,866 pregnant women in China.
- Logistic regression and three machine learning models were employed to assess PCC utilization factors.
- Shapley Additive Explanations (SHAP) decomposition was used to differentiate individual effort from structural circumstance contributions.
Main Results:
- Overall PCC uptake was 42.4%, with significant disparities linked to both individual and structural factors.
- Individual factors, particularly pregnancy intention and PCC knowledge, were the strongest predictors, explaining 74.1-93.6% of variation.
- Structural factors, such as local maternal and child health institution promotion, remained influential, explaining nearly half of the disparity for women with unplanned pregnancies.
Conclusions:
- Access to universal preconception care remains stratified by structural opportunity, influencing individual utilization.
- While individual knowledge and intention are important, they are shaped by broader social conditions.
- Addressing PCC inequality requires integrated strategies promoting individual empowerment alongside systemic equity in maternal health.
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