Public healthcare system preparedness and community perceptions on comprehensive preconception care service delivery in Maharashtra, India.

Background and objectives Preconception care (PCC) comprises a set of biomedical, behavioural, and social interventions provided before conception to improve maternal and neonatal outcomes. PCC remains a critical missing link in the continuum of reproductive healthcare in India. This study assessed public health-system preparedness and community perception related to PCC service delivery in Maharashtra. Methods A mixed-method, pre-intervention situational analysis was conducted to assess public health-system preparedness and community perceptions regarding PCC service delivery in selected districts of Maharashtra, India. Using stratified purposive sampling, 31 public health facilities were assessed using a facility checklist adapted from World Health Organization (WHO) SARA (Service Availability and Readiness Assessment) domains and mapped to WHO health system building blocks. Additionally, 143 key informant interviews (KIIs) were conducted among healthcare providers, and 20 focus group discussions (FGDs) were conducted with newly married couples and mothers-in-law across rural (tribal and non-tribal) and urban (slum and non-slum) settings. Qualitative findings were thematically analysed using the social ecological model. Both models were triangulated using a COM-B (capacity, opportunity, motivation→ behaviour) framework. Results All assessed facilities had basic infrastructure and manpower; however, PCC services were largely restricted to anaemia prophylaxis and family planning commodities. Major systemic challenges included the absence of PCC-specific guidelines, irregular supply of essential medicines and diagnostics, limited health management and information systems (HMIS) integration, weak policy coordination, inadequate human resources, and referral pathways. From the community perspective, PCC awareness was negligible; misconceptions linked it to infertility care, and family gatekeeping limited women's autonomy. Gender norms and poor male involvement further constrained service uptake. Interpretation and conclusions Although Maharashtra has favourable policy support for PCC through the Mission Vatsalya initiative, significant gaps persist in the health system's readiness and community awareness. Developing PCC-specific operational and technical guidelines, capacity building, provision of information, and education material, PCC indicator integration in HMIS, and demand generation, coupled with male involvement, can optimise PCC uptake and improve PCC service utilisation.