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INTRODUCTION
Preconception care (PCC) refers to a set of interventions delivered before pregnancy aimed at optimising the health and well-being of women and couples, reducing risk factors and creating conditions that support healthier pregnancies and future generations1,2. The current maternal and child continuum of care typically extends from pregnancy through childbirth, the postnatal period, and early childhood, leaving a gap in the preconception period. This gap, which is generally more pronounced for adolescent girls and young women, is a time when health risks such as undernutrition, anaemia, unmanaged chronic conditions, substance use, or exposure to gender-based violence can develop and persist into pregnancy3. Because conception is often unplanned and antenatal care usually begins only after the critical early weeks of organogenesis, many of these risks remain unaddressed by the time pregnancy is recognised, increasing the likelihood of complications and averse health outcomes for mothers and newborns. PCC fills this gap by acting before conception, ensuring risks are reduced and protective factors strengthened early on.
While the content of PCC varies by context, core components typically include reproductive planning and birth spacing, nutrition and micronutrient supplementation, prevention and management of chronic conditions, mental health support, prevention and response to intimate partner violence and other forms of gender-based violence, infectious disease prevention and care, or risk reduction for harmful substances and environmental hazards.
PCC can be approached from both individual and population perspectives4. At the individual level, it is delivered directly to women or couples, regardless of whether they are actively planning a pregnancy. For those intending to conceive, PCC may involve counselling, vaccination, or the management of chronic conditions. For those who are not planning but might become pregnant in the near future, it can take the form of risk assessments and preventive advice during routine consultations. At the population level, the focus is broader. Many measures are not labelled explicitly as preconception interventions but nonetheless improve the health of women of reproductive age and may improve outcomes of future pregnancies. For example, campaigns promoting healthy diets and physical activity aim primarily to reduce the risk of non-communicable diseases (NCD) in the general population5. Yet, they also contribute to healthier pregnancies when conception occurs, although this is often viewed as a secondary aim or a spillover effect. On the contrary, other population-based measures, such as folic acid fortification, are specifically intended to prevent adverse pregnancy outcomes, like neural tube defects6-8. This highlights that PCC is not a standalone programme but rather a flexible concept that can take different forms, be embedded into many different health and social programmes, and respond to different timelines in people’s lives.
Despite clinical logic and call for action, PCC remains relatively unknown and under-prioritised, notably in LMICs1,2. Contributing factors include limited awareness, fragmented delivery, and competing priorities in overstretched systems9-11. A particularly important barrier is economic framing. Indeed, unlike immunisation or selected NCD interventions, PCC lacks visible investment cases that quantify the costs of inaction and the returns to investment12,13. In global health policy, decisions are often influenced not only by epidemiological and clinical evidence but also by the ability to demonstrate the economic value of acting. Investment cases, including cost-of-illness studies and economic evaluations, have played a decisive role in mobilising investment in areas such as vaccination and non-communicable disease prevention and control. In recent years, organisations such as the United Nations Development Programme (UNDP) and the World Health Organisation (WHO) have actively supported the development of investment cases for health, providing governments with tools to demonstrate the social and economic returns of targeted interventions14,15. In budget negotiations, ministries of finance respond to credible economic narratives as much as to epidemiology.
Without an explicit economic narrative, PCC is likely to remain overlooked by planners and treasuries; with one, it becomes a strategic investment in social development. The aim of this article is to synthesise and reflect on a series of our previously published studies conducted between 2021 and 2025 on the economics of preconception health and care in LMICs. This paper brings together key findings and methodological insights to draw lessons for policy, research, and practice.
OVERVIEW OF THE RESEARCH PROJECT AND SOURCES OF EVIDENCE
This article synthesises findings and lessons learned from a multi-component research project conducted between 2021 and 2025, exploring the economics of preconception health and care in LMICs16-19. The project was designed to fill a critical evidence gap by linking preconception health with economic and societal outcomes and by developing practical analytical tools to support policy dialogue. It drew on secondary data sources and existing literature to test and adapt methods suitable for LMIC contexts. The Project consisted of several interrelated components that together provide a coherent narrative on the value of investing in PCC. These components addressed complementary questions: (1) Pathways and mechanisms: How does preconception health influence maternal, perinatal, and child outcomes? (2) Economic burden: What are the costs of inaction on preconception health for societies and economies? (3) Returns on investment: What economic benefits could be generated by implementing selected preconception interventions?
The project’s components are summarised below and illustrated in Figure 1.
Figure 1 Steps and components in the research on the economics of preconception health and care in LMICs
Scoping review and causal-loop diagram (CLD) analysis: A synthesis of meta-analyses assessing how modifiable preconception risk factors and interventions affect maternal and child health outcomes. The CLD provided a systems-thinking framework visualising the complex pathways connecting preconception determinants with pregnancy and child health16.
Country-level and multi-country cost-of-illness (COI) analyses: Studies quantifying the economic burden of poor preconception health in Nigeria and, subsequently, across fifteen LMICs in sub-Saharan Africa and Asia. These analyses combined epidemiological and economic data to estimate productivity and societal losses attributable to preconception risk factors17,18.
Modelling-based cost–benefit analyses (CBA): Simulation studies assessing the potential economic returns of two PCC-related strategies in Senegal—preventing child marriage and expanding access to modern contraception. The models translated expected health gains into economic benefits, generating benefit–cost ratios to inform policy prioritisation19.
This article integrates evidence and reflections to identify cross-cutting insights relevant to policy, research, and programme implementation.
SYNTHESIS OF FINDINGS
This section integrates insights from the previously published components of the research project to illustrate how preconception health shapes maternal and child outcomes, how inaction translates into measurable economic losses, and how investments in preconception strategies can yield substantial returns.
How does PCC link to maternal, perinatal, and child health outcomes?
As detailed in Poix & Elmusharaf (2023)16, a scoping review of meta-analyses examined the associations between modifiable preconception risk factors and adverse maternal and child outcomes, complemented by a causal loop diagram (CLD) to visualise systems interactions. This method enabled us to map the breadth of evidence, highlight consistent associations, and identify areas where knowledge remains limited. CLDs are tools from systems thinking that illustrate how elements of a system interact over time20-22. In the context of PCC, where biological, behavioural, and social determinants intersect in complex ways, the CLD allowed us to bring these relationships together in a single framework. Beyond analysis, it also served as a communication tool, translating complexity into a format that is easier for policymakers and practitioners to grasp.
The review identified nine preconception risk factors consistently linked to different adverse health outcomes: adolescent pregnancies, short birth intervals, pre-pregnancy underweight, overweight and obesity, micronutrient deficiencies, smoking, alcohol use, vaccine-preventable diseases, and exposure to abuse or violence before pregnancy. These risks were associated with a wide spectrum of maternal and child health outcomes, including preterm birth, small-for-gestational-age infants, congenital anomalies, gestational diabetes, hypertensive disorders, maternal haemorrhage, and maternal anaemia. Ultimately, these pathways contribute to increased risks of maternal mortality, child mortality, and stillbirth.
Some of these pathways were supported by especially robust evidence across multiple meta-analyses. Reproductive timing stood out as a key determinant. Adolescent pregnancy and short birth intervals were consistently associated with preterm birth, small-for-gestational-age infants, maternal anaemia, and stillbirth. Women’s nutritional status before conception was another powerful driver. Being underweight before pregnancy increased the risks of growth restriction and maternal complications, while overweight and obesity substantially raised the likelihood of gestational diabetes, hypertensive disorders, congenital anomalies, and stillbirth. Micronutrient deficiencies, particularly inadequate folate intake, were closely linked to neural tube defects and other congenital anomalies, providing strong evidence for supplementation and fortification strategies.
Other associations were less frequently studied but remain important. Smoking and alcohol use before conception were associated with congenital anomalies and poor foetal growth. Infections that could be prevented through immunisation contributed to complications during pregnancy and at birth. Finally, exposure to violence or abuse before conception was also linked to higher rates of preterm birth, showing also how social conditions shape reproductive outcomes.
The review further identified interventions that can substantially reduce these risks when implemented before pregnancy. Folic acid and other micronutrient supplementation or fortification lowered the incidence of neural tube defects, anaemia, and preterm birth. Family planning and sexual risk-reduction strategies reduced adolescent pregnancies and short birth intervals, in turn lowering mortality and morbidity risks during pregnancy, childbirth, and after. Programmes promoting healthier behaviours before conception, such as physical activity and avoidance of tobacco or alcohol, reduced the likelihood of gestational diabetes, preeclampsia, and related complications. A central finding is that the prevention of unintended pregnancies plays a pivotal role in maximising these benefits, since it enables women and couples to enter pregnancy at a time when health risks are reduced and protective factors optimised.
The CLD integrated these findings by mapping 29 constructs and 64 linkages across five interrelated subsystems: rapid and repeated pregnancies, nutrition, lifestyle behaviours, vaccine-preventable diseases, and domestic violence. By translating a complex body of evidence into a single diagram, the CLD provides a visual tool that helps policymakers and practitioners see how different determinants are connected and where interventions may have the greatest impact. It showed, for example, how actions that target multiple risk factors simultaneously, such as delaying early pregnancies while improving nutrition and reducing exposure to harmful behaviours, can generate reinforcing effects that multiply health gains across mothers and children. In Figure 2, we present a simplified version of the published CLD, highlighting the pathways by which preconception health affects maternal and child morbidity and mortality.
note: The full version of the CLD is available at Poix et al.16
Figure 2 : Simplified version of the CLD illustrating the pathways by which preconception health affects maternal and child morbidity and mortality.
Together, the scoping review and CLD illustrate that poor preconception health is a major driver of maternal, perinatal, and child morbidity and mortality, but also that several of these risk factors can be mitigated through appropriate action before pregnancy begins. The strongest evidence relates to reproductive timing and maternal nutritional status, although emerging evidence also points to important roles for behaviours, infections, and social determinants. The CLD further illustrates that PCC should not be seen as a narrow clinical package but as a multisectoral strategy that addresses interconnected determinants of health. These findings provided a foundation for the next step, which consisted of assessing the economic burden of poor preconception health and the potential returns on investment of preconception interventions and strategies.
What does it cost not to act, and what can be gained by investing in PCC?
Strengthening the case for PCC requires going beyond clinical evidence alone. For policymakers, two questions are particularly important: what does it cost not to act, and what can be gained by acting? Answering these questions requires economic methods that can quantify both the losses associated with inaction and the potential returns on investment generated by preconception interventions and policies. Among the available approaches, COI studies and CBA are especially relevant, yet they have rarely been applied to PCC. To illustrate how economic reasoning can be integrated into this field, we conducted four studies17-19, which we present below.
The first step was to conduct a COI study to test whether the burden of poor preconception health could be measured in economic terms at the country level17. Nigeria was chosen as a pilot, given its high levels of maternal and child mortality and relatively strong data availability. The analysis focused on six preconception risk factors (adolescent pregnancies, short birth intervals, pre-pregnancy overweight and obesity, folate deficiency, intimate partner violence, and female genital mutilation), which we linked to a set of maternal and child health outcomes using the population attributable fraction (PAF) method. We then expressed the portion of these outcomes attributable to the preconception risk factors in economic terms by combining different valuation techniques (ingredient-based and top-down costing for healthcare use, human capital approach for productivity losses associated with premature mortality and impaired development). The results showed that poor preconception health generated losses of US$3.3 billion in Nigeria in 2020, most of which were due to foregone productivity due to premature mortality. Beyond the figures themselves, this work demonstrated that PCC can be framed not only as a health sector issue but also as a driver of macroeconomic losses.
Building on this pilot test, we extended the methodology to fifteen LMICs across sub-Saharan Africa and Asia18. This step was crucial for testing its transferability and providing comparative evidence. Several refinements were made. First, we narrowed our scope of health outcomes to include perinatal mortality only, the outcome most consistently linked to all selected risk factors and supported by the strongest causal evidence. Second, we excluded folate deficiency because comparable data were lacking across country settings. Third, we complemented the human capital approach with a value of a statistical life (VSL) approach, which better reflects the societal value of lives lost in contexts where a large share of the population works outside the formal economy. This multi-country analysis showed that poor preconception health was associated with losses of several billion international dollars, representing a sizeable share of national GDPs (Box 1). These findings confirm that the economic burden of inaction is substantial and widespread, and that methods developed for a single country can be adapted for use across diverse contexts.
Box 1 : The economic burden of poor preconception health in 15 LMICs (2020)18
While COI studies reveal what countries stand to lose, policymakers also need evidence of what can be gained. To this end, we conducted modelling-based CBAs of two interventions using the case of Senegal19. The choice of Senegal was justified by the availability of recent and reliable data from the Demographic and Health Survey (DHS), which provided a strong empirical basis for modelling. The first CBA assessed the economic value of preventing child marriage, a major driver of adolescent pregnancy that, in turn, increases the risks of neonatal deaths and stillbirths. Using a cohort-based simulation model, we projected the impact of a community intervention designed to reduce child marriage rates in a virtual cohort of adolescent girls aged 15 at the beginning of the intervention. After three years, the results showed a clear reduction in adolescent pregnancies, neonatal deaths, and stillbirths. These gains translated into a benefit–cost ratio (BCR) above 4 (Box 2). These results demonstrate that social interventions, which are not typically framed as health measures, can deliver significant health and economic returns, even when viewed through a preconception lens alone.
Box 2 : Modelling-based cost-benefit analyses of preconception interventions in Senegal19
The second CBA focused on family planning, widely recognised as a cornerstone of PCC. The analysis simulated a scenario in which 80% of the current unmet needs for modern contraception were satisfied over a 15-year period in Senegal. Increasing access to family planning was projected to result in large reductions in unintended pregnancies, maternal deaths, and under-five mortality. When valuing only maternal deaths averted, the benefit–cost ratio was estimated at 2.7, indicating that each dollar invested would generate almost three dollars in economic returns (Box 2). Framed within PCC, family planning thus emerges not only as a public health and rights-based priority but also as a sound economic investment.
LESSONS AND RECOMMENDATIONS
This body of work highlights that poor preconception health is not only a clinical concern but also a driver of economic and societal losses. At the same time, investments in PCC have the potential to generate substantial benefits across health, education, productivity, and intergenerational well-being. Despite this relevance, PCC remains barely visible in global and national agendas. It is essential to move beyond viewing PCC as a narrow health intervention and to position it as a broader development priority. By shifting this narrative and making PCC more visible, there is a real opportunity to mobilise greater political commitment and sustained investment. In this section, we outline key recommendations for policy, practice, and research that can support this shift.
Recommendations for policy and practice
Recognising and leveraging existing efforts
Many interventions that already exist outside the maternal and child health field influence preconception health, even if they are not described in those terms. Preventing child marriage, improving nutrition, supporting adolescent health literacy, or preventing female genital mutilation all have measurable impacts on pregnancy outcomes when assessed through a preconception lens. Yet these effects are rarely measured and made visible. Governments and partners should therefore start by mapping existing policies and programmes that affect preconception health, directly or indirectly, to identify opportunities for integration and coordination. Such mapping exercises can help reveal that PCC is not an additional burden but rather a cross-sectoral priority that builds on what is already being done.
Reframing PCC as a strategic development investment
To raise the profile of PCC, it is necessary to reframe it as an investment in human capital and sustainable development rather than as an expenditure. Improvements in population health are consistently associated with productivity gains and economic growth, and PCC is no exception. By reducing maternal and child mortality, lowering healthcare costs, and enabling better educational and employment outcomes, PCC contributes to the health, economic, and social development of communities. This framing is more likely to appeal to policymakers, whose perspectives extend beyond epidemiological data to include economic considerations.
Strengthening data and measurement systems
One of the challenges faced during this research work was the scarcity of data on preconception risk factors in LMICs. Information on micronutrient deficiencies, substance use, or mental health, for example, is often collected during antenatal care but rarely measured before pregnancy. This limits the ability to monitor progress or to conduct robust economic analyses. Strengthening surveillance systems and household surveys so they capture preconception indicators is therefore a priority. Integrating such measures into health information systems would not only improve health system planning and resource allocation towards PCC but also strengthen the evidence base needed to make a convincing investment case.
Encouraging local economic evaluations
The analyses presented here demonstrate how economic methods can be applied to PCC, but they are illustrative only. Their insights become most powerful when countries generate results grounded in their own demographic, epidemiological, and economic contexts. Governments should be encouraged to undertake country-led economic evaluations, using local data and adapting methods to their priorities. This should apply not only to health-sector investment cases in reproductive, maternal, newborn, and child health but also to other sectors such as education, gender, and social protection. In this way, the broader impacts of non-health programmes on pregnancy, maternal and child health outcomes can be better recognised.
Scaling up interventions with high returns
The analyses on child marriage prevention and family planning in Senegal provide concrete examples of PCC interventions that deliver significant economic returns. These interventions should be seen as early opportunities for policy, especially in settings where child marriage rates, adolescent pregnancies, short birth intervals, and unmet contraceptive needs remain high. While more evidence is needed to assess the generalisability of these findings across different contexts, scaling up these interventions may contribute to reducing maternal and child mortality and morbidity.
Recommendations for research
Broadening the scope of evaluated interventions
The evidence base for the economics of PCC remains limited, with most studies focusing on biomedical interventions in high-income settings. Expanding the scope of evaluation to include population-level measures relevant to LMICs, such as the prevention of female genital mutilation, the reduction of overweight and obesity among women of reproductive age, or initiatives to improve adolescent health literacy, would help capture the wider determinants of preconception health. Unlike purely clinical or individual-level interventions, these measures address upstream social, cultural, and behavioural factors that shape reproductive health, and their benefits often extend beyond the preconception period to improve overall population wellbeing.
Strengthening evidence of effectiveness
For several preconception interventions, robust data on effectiveness are still lacking. Without this evidence, economic evaluations risk being speculative. Longitudinal studies and intervention trials are needed to establish not only what works but also to quantify the magnitude of intervention effects. This is particularly important in areas such as substance use, mental health, and men’s engagement in preconception health. Generating stronger evidence on intervention effectiveness should be a priority, as this will reinforce confidence in PCC, support its integration into broader health and development agendas, and provide a firmer foundation for future economic analyses.
Advancing methods and innovation
The approaches used in this research, including systems thinking, COI analyses, and simulation-based CBAs, illustrate how diverse methods can be combined to inform the economics of PCC. Building on this foundation, these approaches should be extended to other interventions, risk factors, and country contexts. Simulation modelling has particular potential as it enables researchers to bring together data from multiple sources, explore scenarios, and project long-term and intergenerational effects that would be difficult to measure directly. Nevertheless, modelling should be used carefully. Uncertainties are inevitable, and results are only as robust as the data and assumptions that underpin them. To maintain credibility, models should always include sensitivity analyses, be calibrated to local trends, and clearly document their assumptions. In this way, modelling can complement empirical research and provide timely insights that are relevant for policy.
Addressing ethical and equity considerations
Future research should also give greater attention to the ethical dimensions of PCC. It is important to avoid framing all women of reproductive age as potential mothers and to design interventions that are inclusive and respectful of reproductive choices. At the same time, the role of men in shaping reproductive outcomes should be more systematically addressed, both in research and in programme design. Men influence reproductive health not only through shared decision-making and health behaviours, but also through their support for women’s access to care and the broader social norms they help reinforce. Finally, economic frameworks should also aim to capture equity, empowerment, and intergenerational effects that are central to PCC. Although challenging to quantify, these dimensions reflect how PCC contributes to healthier families and societies beyond immediate health outcomes.
CONCLUSION
The economics of preconception health and care remain an underdeveloped but crucial field. Our work illustrates how economic analyses can be applied to PCC in LMICs, showing both the costs of inaction and the potential benefits of interventions. Our findings suggest that investments in PCC are not only morally compelling but also economically sound, with implications that extend well beyond the health sector. To realise this potential, it is essential to make PCC visible within health and development agendas and to shift the narrative from perceiving it as an expense to recognising it as a strategic investment in health, economic, and social development.
