The Forgotten Preconception Trimester
Why America must care for women before they are pregnant. And why it fails terribly.
A patient once told me, “I’ll start taking care of myself once I’m pregnant.” She meant well—she wanted to do the best for her future baby. But she didn’t realize that by the time the pregnancy test turned positive, the most critical window for prevention had already passed.
In obstetrics, we talk endlessly about the three trimesters of pregnancy, and more recently the “fourth trimester” of postpartum care. But we rarely acknowledge the trimester that comes first—the preconception trimester. The health of a woman before she conceives is one of the strongest predictors of whether she and her baby will survive pregnancy and childbirth. And yet in the United States, preconception care is almost invisible.
Only about one in four pregnant women in the United States—roughly 24%—report having a preconception care visit with a healthcare provider in the year before becoming pregnant. Far fewer US women than European women receive a dedicated preconception care visit before pregnancy, and general healthcare contact before pregnancy is higher and more universal in Europe.
Analyses of large representative databases, including Medicaid claims and the CDC's PRAMS survey, consistently indicate this low utilization rate, despite recommendations that all women of reproductive age receive preconception counseling. This means that a substantial majority of pregnancies begin without the benefits of preconception health optimization and risk assessment.
The First Missed Opportunity
The U.S. has no systematic approach to preconception care. There are virtually no dedicated clinics, few primary care practices that address it, and little public health infrastructure to support it. Most physicians are trained to respond once pregnancy has begun, not before.
Women face significant barriers to accessing preconception care because there is no dedicated CPT billing code for a preconception visit, meaning providers cannot reliably bill for these services or be reimbursed under Medicaid. Forced to use general evaluation and management (E/M) codes, such as 99213 or 99214, Medicaid reimbursement to doctors typically ranges from just $35 to $100 per visit, and even these payments may not be consistently approved for preconception counseling. Which doctor or clinic would want to iaccept or invite patients for a visit for this low amount which optimally takes 30-60 minutes or more?
As a result, women who need counseling about health optimization before pregnancy struggle to obtain these visits, since physicians may be disincentivized to offer preconception care when reimbursement is uncertain or inadequate.
The consequence is predictable: women enter pregnancy without ever receiving guidance on how to prepare their bodies, adjust their medications, or address health risks.
Think about the basics:
Folic acid supplementation must start before conception to reduce neural tube defects. By the time a woman realizes she is pregnant, the neural tube has usually already closed.
Medication safety is rarely reviewed until after conception, even though some commonly prescribed drugs can harm fetal development.
Weight management before pregnancy can reduce the risk of preeclampsia, gestational diabetes, and cesarean birth.
Substance use—alcohol, smoking, recreational drugs—should be stopped before conception, not after.
Chronic diseases such as hypertension and diabetes need careful control prior to pregnancy to reduce the risk of complications, stillbirth, and maternal death.
Each of these steps requires foresight, counseling, and access to care. And yet most women receive none of it.an’t even
How can we effectively say we want to fight maternal and neonatal/infant mortality when we can’t even have preconception visits available?
Why Timing Matters
Pregnancy is not a “fresh start” biologically. It is a stress test imposed on the body. If blood pressure is poorly controlled before conception, the added demands of pregnancy can push it to dangerous levels. If blood sugar is high, the risks of miscarriage, congenital anomalies, and stillbirth multiply. If folic acid is missing, no amount of supplementation started after a positive test can undo that deficit.
In other words, the clock does not start at conception—it starts long before. But our system treats pregnancy as if it begins only when a woman shows up for her first prenatal visit. By then, the chance to prevent many complications has already been lost.
How Other Countries Do Better
This neglect is uniquely American. Other high-income countries treat preconception care as a cornerstone of maternal health. In the Netherlands, the U.K., and parts of Scandinavia, women of reproductive age are routinely offered preconception counseling. Public health campaigns promote folic acid as a universal supplement. Chronic diseases are managed with pregnancy in mind.
The results are clear: lower rates of maternal mortality, fewer preventable birth defects, and healthier infants. These countries recognize what the U.S. refuses to: that pregnancy outcomes are shaped long before conception.
The Equity Gap
The absence of preconception care in the US deepens existing inequities. Black and Hispanic women in the U.S. face higher rates of hypertension, obesity, and diabetes. They are also less likely to have consistent access to primary care. When preconception care is absent, the very populations already at highest risk are the ones most harmed.
This helps explain why maternal mortality is nearly three times higher among Black women than white women. It is not just what happens in the delivery room—it is the cumulative neglect of health across the life span, compounded by racism, poverty, and structural barriers.
Why Doctors Don’t Talk About It
Many clinicians want to help women prepare for pregnancy but face structural roadblocks. Insurance reimbursement rarely covers preconception counseling. Primary care visits are already rushed, and reproductive health often takes a back seat to acute concerns. OB/GYN practices usually see women once they are pregnant, not before. The result is a gaping hole in care that no specialty has claimed as its responsibility.
We have normalized this neglect to the point that most women—and many doctors—accept it as unavoidable. But it is neither unavoidable nor acceptable.
What Preconception Care Should Look Like
A real system of preconception care would include:
Universal folic acid supplementation for women of reproductive age, supported by public health campaigns and free access to vitamins.
Medication reviews during routine visits, ensuring women of childbearing potential know whether their prescriptions are safe for pregnancy.
Screening and management of hypertension, diabetes, thyroid disease, and obesity before pregnancy.
Substance use counseling as part of reproductive health, not a separate, stigmatized service.
Accessible clinics where women planning pregnancy—or even just considering it—can get targeted counseling.
Insurance coverage that reimburses preconception visits just as it does prenatal ones.
This is not high-tech medicine. It is simple, low-cost prevention. But it requires acknowledging that the preconception period matters as much as any trimester of pregnancy.
The Broader Lesson
The Forgotten Preconception Trimester is part of a larger American pattern: we wait until people are sick before we act. We treat complications rather than prevent them. We invest in intensive care units but not in community clinics. Nowhere is this more tragic than in maternal health, where the consequences are measured in mothers and infants who never had a chance.
A Call to Action
If we are serious about reducing maternal and infant mortality, we cannot continue to ignore the preconception period. Expanding prenatal care is not enough. Expanding postpartum care is not enough. We must begin before pregnancy begins.
Every high-income nation that outperforms the U.S. on maternal outcomes does one thing consistently: it integrates women’s health across the life course, not just during pregnancy. We can do the same.
Public health must guarantee folic acid access.
Primary care must treat preconception counseling as routine, not optional.
Insurance must reimburse for it.
And we as physicians must speak about it openly—reminding women that their health before pregnancy is as important as during it.
The United States cannot keep pretending pregnancy begins with a positive test. The first and most crucial trimester is the one we don’t talk about. Until we build a system that addresses it, maternal and infant mortality will remain unacceptably high.
Every pregnancy begins before conception. The tragedy is that our health system still hasn’t caught up.