As U.S. infant mortality remains relatively unchanged and maternal mortality is rising, it is increasingly clear that service providers need to address many of the modifiable risks that determine birth outcomes prior to pregnancy. Health professionals have promoted preconception care for decades as a way to improve women's and infant's health. Yet few women receive this type of care. Strategies to identify and reduce maternal preconception health risks will require system-level changes and a paradigm shift toward assessing pregnancy desires and risks at every encounter and in every setting possible. The author presents current strategies and opportunities for advancing preconception wellness.