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Background: Preconception care (PCC) is an important form of primary health care that aims to identify risks, offer patient education and evidence based interventions prior to conception in order to improve maternal and fetal short and long term health outcomes. Despite the benefits of PCC, the global levels of utilization are still low, more so in developing countries and in the rural settings. This study aimed to determine the difference in the level and determinants of PCC in both urban and rural settings in Kenya. Objectives: The primary objective of this study was to compare PCC among pregnant women in Aga Khan University Hospital, Nairobi (AKUH, N) (urban) and Maragua Level Four Hospital (MLFH) (rural). The secondary objective was to determine the factors affecting PCC among pregnant women in the two hospitals. Design and Methodology: Unselected pregnant women seeking antenatal care (ANC) were recruited consecutively at the Mother and Child Health (MCH) clinics in AKUH, N and MLFH. The study design was a mixed method study that employed a cross-sectional approach to determine the level of PCC, using a 5-10 minutes self-administered questionnaire, and a qualitative approach to assess factors affecting PCC using a semi-structured interview guide. Quantitative data was analyzed using SPSS version 22. Qualitative interviews were transcribed verbatim, a thematic framework was thereafter manually constructed through coding, creating categories, sub-themes and themes. Indexing, charting, mapping and data interpretation were thereafter carried out. Results: A total of 194 pregnant women were recruited, 97 in each setting (rural and urban). Of these, 21 women were selected through purposive sampling to participate in in-depth interviews for the qualitative aspect of the study. Saturation of themes occurred after 13 interviews (7 at AKUH and 6 at MLFH) after which 4 more interviews were conducted at each site to confirm saturation. Of the total participants, 25.8% received PCC. There was a significant difference (p < 0.01) in PCC between the rural and urban participants with an OR of 0.3 (0.19-0.72, 95 % CI). Univariate analysis of possible related factors showed that age, marital status, education, parity and occupation had potential effect on PCC. Transcription, coding and thematic analysis of the in-depth interviews yielded 97 categories which were merged into 39 sub-themes and subsequently into 12 main themes. Eleven of the main themes were identified as factors affecting PCC while one theme contained suggested strategies of increasing PCC awareness and utilization. The dominant themes
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