ArticleFrontiers in public health2026
Inequality in preconception care utilization based on the opportunity inequality framework: evidence from explained machine learning.
Article in Frontiers in public health, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: Despite the universal availability of free preconception care (PCC) in China, substantial disparities in utilization persist. It remains unclear how much of this reflects structural barriers versus individual shortfalls, and clarifying this balance is critical for designing equitable, accountable maternal health policy. Methods: We conducted a multi-center cross-sectional survey across ten medical facilities in China from July 1, 2023, to July 1, 2024, including 8,866 pregnant women. Guided by the Equality of Opportunity framework, we applied logistic regression to assess PCC factors and three machine learning models to assess factors' contributions of PCC utilization. Shapley Additive Explanations (SHAP) decomposition quantified the contribution of individual-level "effort" versus structural "circumstance" factors. Subgroup analyses explored heterogeneity by education level, urban-rural residents, whether or not the annual PCC promotion was accepted at local MCH institutions, and pregnancy intention status. Results: Overall PCC uptake was 42.4%, with disparities strongly associated with individual-level factors as well as structural determinants. Effort-related variables, particularly pregnancy intention and knowledge of PCC, were the strongest predictors across all models, accounting for 74.1-93.6% of explained variation. However, circumstance factors, including annual PCC promotion at local maternal and child health institutions, remained influential, especially among vulnerable subgroups such as women with unplanned pregnancies, for whom structural factors explained nearly half of the disparity. Conclusion: Our findings reveal that even in systems offering universal coverage, access to PCC remains stratified by structural opportunity. Although individual-level knowledge and intention are key levers, they are themselves shaped by broader social conditions. Addressing PCC inequality thus requires integrated strategies that promote both individual empowerment and systemic equity.
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