From Moral Commitment to Systemic Neglect: Health System Perspectives on Preconception Care in Ethiopia From Healthcare Workers, Leaders, and Policymakers.
OBJECTIVE(S) To explore how healthcare workers, managers, and policymakers understand, perceive, and operate preconception care (PCC). DESIGN An interpretive descriptive qualitative study was conducted (April-September 2025) in two government hospitals. Data from interviews, focus groups, document review, and observations were analyzed using constant-comparative methods to generate an explanatory account of PCC practice. SAMPLE Thirty-six participants were purposively recruited, including healthcare workers, hospital managers, policymakers, health bureau staff, and NGO stakeholders. Data were collected in Amharic, transcribed, translated, and analyzed inductively, focusing on patterns, tensions, and system-level influences. RESULTS Preconception care emerged as structurally unsupported yet sustained through individual effort, shaped differently across system levels. Frontline providers delivered it through moral commitment and improvisation within routine services, rendering it invisible and inconsistent. Fragmented knowledge, shaped by a biomedical focus, limited training, and confusion with antenatal care, further undermined consistent delivery. Managers described the absence of training, supervision, and performance indicators, limiting accountability and integration into service delivery. Policymakers emphasized it as a strategic priority but highlighted gaps in operationalization, coordination, and resource allocation. Across levels, gendered norms and reliance on community trust networks shaped access and reinforced inequities, revealing a persistent misalignment between policy intent and practice. CONCLUSIONS PCC functions as an informal practice sustained by individual agency within weakly institutionalized systems. Strengthening implementation requires bridging policy and practice through system integration, managerial accountability, and gender-responsive, community-engaged care models.