Systemic gaps in preconception health surveillance: Why global monitoring fails to capture structural inequities in reproductive care

Indigenous knowledge systems frame preconception health as a relational process embedded in land, community, and spiritual well-being, rather than a biomedical checklist. Traditional practices like seed-saving ceremonies (e.g., among the Navajo) or dietary protocols (e.g., Inuit *uunaqtuut*) prioritize environmental harmony as a precursor to healthy pregnancies. Current surveillance systems ignore these frameworks, treating Indigenous communities as data sources for Western metrics rather than stewards of their own health knowledge. The absence of Indigenous-led data governance in reproductive health reflects ongoing epistemic violence.

The history of preconception health surveillance is intertwined with eugenics and colonial population control, from 19th-century 'maternal welfare' programs that targeted poor women to 20th-century sterilization campaigns against Black, Indigenous, and disabled people. Modern indicator systems often replicate these power dynamics by prioritizing metrics that align with neoliberal ideals of 'responsible' reproduction, such as employment status or marital stability. The lack of historical accountability in current frameworks ensures that structural harms—like the forced sterilizations in Peru (1990s) or Canada’s Sixties Scoop—remain invisible in data systems. Historical parallels reveal how surveillance is weaponized against marginalized bodies.

Cross-culturally, preconception health is often tied to collective well-being rather than individual choice, as seen in African Ubuntu philosophy ('I am because we are') or the Andean concept of *ayni* (reciprocity). In Japan, *satoyama* (harmonious rural landscapes) are considered essential for healthy pregnancies, linking environmental degradation to reproductive outcomes. Western models, by contrast, isolate 'risk factors' like smoking or obesity without addressing systemic stressors like precarious labor or climate-induced food insecurity. These divergences underscore the need for culturally pluralistic surveillance systems that center community-defined health priorities.

Scientific evidence increasingly shows that social determinants—poverty, racism, environmental toxins—account for 50-70% of adverse pregnancy outcomes, yet surveillance systems prioritize biomedical markers (e.g., folic acid levels) over these drivers. The lack of standardized, intersectional indicators (e.g., disability status, LGBTQ+ identity) means critical risk factors are systematically undermeasured. Emerging research on epigenetics highlights how preconception exposures (e.g., to endocrine disruptors) can alter gene expression across generations, a dimension entirely absent from current monitoring frameworks. Without rigorous, equity-focused methodology, surveillance systems are scientifically flawed.

Artistic and spiritual traditions often encode preconception health as a sacred duty, such as the Hindu *garbhadhana samskara* (preconception ritual) or the African diasporic practice of 'root work' for fertility. Visual art (e.g., Mexican *retablos* depicting pregnancy miracles) and oral traditions (e.g., West African griot narratives) frame reproductive health as part of a larger cosmology, where ancestors, land, and community are active participants. Western surveillance systems, by contrast, reduce health to quantifiable data, erasing the symbolic and emotional dimensions of pregnancy planning. These artistic-spiritual frameworks offer alternative models for holistic care.

Future models of preconception health surveillance must integrate scenario planning for climate collapse, which will disproportionately affect marginalized communities through heat stress, food insecurity, and waterborne diseases. AI-driven predictive analytics could map environmental toxins to pregnancy outcomes, but without participatory design, these tools risk reinforcing biases (e.g., targeting poor women for 'interventions'). Decolonial futures require systems that prioritize community resilience over compliance, such as Indigenous-led environmental health tracking or cooperative childcare networks. The failure to model these pathways ensures surveillance remains reactive rather than transformative.

Marginalized voices—disabled people, LGBTQ+ individuals, survivors of violence, and racialized communities—are systematically excluded from preconception health discourse, despite facing disproportionate barriers to care. For example, disabled people are often deemed 'unfit' for parenthood in medical systems, while trans men and nonbinary people face erasure in pregnancy data collection. Survivors of gender-based violence may avoid preconception care due to trauma triggers in clinical settings, yet their experiences are absent from indicator frameworks. Centering these voices requires dismantling ableist, cisnormative, and racist assumptions in both care and surveillance.