If all women of reproductive age, or at least those at elevated risk, are to benefit from preconception services, the use of family planning services must be increased and the content of such services expanded. Family planning services are essential for preconception care for at least two reasons. First, in the absence of such services, pregnancies will occur that have not benefited from preconception care. Preconception care during the reproductive years is dependent on women and men planning their pregnancies, not only in respect to their timing but also to health-related factors that would maximize the chances for a healthy pregnancy and a healthy infant. In the absence of such care, offered by family planning services, many pregnancies will not benefit from preconception advice. Second, family planning counseling provides an opportunity for promoting and providing preconception care. At the same time women and their partners are receiving advice about family planning, they can also receive instruction about the range of activities that lead to healthy pregnancies and healthy infants. Unfortunately, several factors prevent family planning from reaching its maximal potential for preconception care. These include underutilization of family planning services and inadequate attention to preconception counseling during family planning visits. Underutilization of family planning services Two types of data point to underutilization of family planning services with implications for decreasing opportunities for preconception care: the percentage of women actually seeking family planning services and the percentage of unintended pregnancies. Visits for family planning 1 Pregnancy planning Women of Crisis afford 2 birth 3 pregnancies 4 5 6 Reasons for underutilization 7 8 Financial issues 9 10 Availability 11 12 13 Limited contraceptive methods 1 14 7 8 The availability of one effective family planning method, emergency contraception (meant as back-up protection, not as a primary method), is currently limited by the refusal of the federal Food and Drug Administration to allow it to be sold over the counter and by the refusal of some pharmacists to fill prescriptions for this medication. Inadequate attention to preconception counseling 15 16 Approaches to increasing utilization 17 18 19 20 Approaches to improving content 15 21 22 In all likelihood, it may be most difficult to change patterns of family planning practice among physicians in private practice. In contrast, those in HMOs have the potential for exposure to more education about the need for such counseling. The establishment of standards for family planning services by the Health Plan Employer Data and Information Set (HEDIS) might also accelerate change. However, standard setting and financial and other incentives may be most effective when used with community health centers and health department and other publicly-funded sites of family planning services - as the women who use seek family planning at these sites may be those most in need of preconception care. Because such sites are funded by federal, state, and local governments, these units can insist that preconception care be integrated into their family planning services. Conclusions Progress towards preconception care for all women will only be possible if a larger percentage of women and men plan their pregnancies. At present, although visits for contraceptive advice and methods provide an excellent opportunity for counseling about ways to achieve healthy pregnancies and healthy infants through preconception care, this potential is not being achieved. Increased use of family planning and increased attention to preconception care within family planning services may require that additional resources be devoted to public and professional education and to service delivery standards and financing.