Preconception care utilization and geographic disparities in conflict- affected Tigray, Ethiopia: a community-based cross-sectional study

Abstract Background Preconception care (PCC) enhances maternal and newborn health outcomes. In conflict-affected areas where healthcare is disrupted, women encounter obstacles in accessing maternal health services, which reduces PCC utilization. This study explored PCC usage, geographic disparities, and associated factors among women in conflict-affected Tigray, Ethiopia. Methods A community-based cross-sectional survey was carried out from September to November 2025 in 32 districts across six accessible zones. Women with children aged 24–36 months were selected using stratified multistage cluster sampling. The receipt of 15 recommended interventions before the index pregnancy was categorized as no, suboptimal, or optimal PCC utilization. Because the proportional-odds assumption was violated, generalized ordered logistic regression was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for two cumulative thresholds. Results Among 9,511 participants, 74.7% reported no PCC, 6.1% suboptimal PCC, and 19.2% optimal PCC. Optimal utilization ranged from 0.4% to 61.0% across districts. Compared with the Eastern Zone, women in all other zones had higher adjusted odds of PCC utilization; the strongest association was observed in the Southeast (aOR 7.30 at both thresholds). Women aged 25–34 years (aOR 1.13) and ≥ 35 years (aOR 1.25) had higher odds than women aged 15–24 years. Internally displaced women had higher odds than host-community women (aOR 1.80). Ownership of one, two, or three types of electronic communication devices was positively associated with utilization (aOR range: 1.18–3.48), as was living within 4 hours' walking distance of a health centre or hospital (aOR range: 1.30–1.46). Conclusions PCC utilization was low and geographically unequal in conflict-affected Tigray. Recovery strategies should integrate PCC into routine primary and reproductive health services, prioritize districts with the lowest coverage, strengthen community outreach, use inclusive communication approaches, and address physical barriers to care.