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BMC Public Health. 2019 Feb 27;19(1):236. doi: 10.1186/s12889-019-6533-7.

Area-level deprivation and preterm birth: results from a national, commercially-insured population.

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Yale School of Public Health, PO Box 208034, New Haven, CT, 06520-8034, USA.
Yale School of Public Health, PO Box 208034, New Haven, CT, 06520-8034, USA.
Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, 100 Cambridge Street, Boston, MA, 02114, USA.
Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, PO Box 208063, New Haven, CT, 06520, USA.
Health Care Cost Institute, 1100 G Street NW, Suite 600, Washington, DC, 20005, USA.
Medtronic, 950 F Street NW, Suite 500, Washington, DC, 20004, USA.
Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA.
Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware Street SE, Minneapolis, MN, 55455, USA.
Yale-NUS College, 20 College Avenue West #03-401, Singapore, 138529, Singapore.



Area-level deprivation is associated with multiple adverse birth outcomes. Few studies have examined the mediating pathways through which area-level deprivation affects these outcomes. The objective of this study was to investigate the association between area-level deprivation and preterm birth, and examine the mediating effects of maternal medical, behavioural, and psychosocial factors.


We conducted a retrospective cohort study using national, commercial health insurance claims data from 2011, obtained from the Health Care Cost Institute. Area-level deprivation was derived from principal components methods using ZIP code-level data. Multilevel structural equation modeling was used to examine mediating effects.


In total, 138,487 women with a live singleton birth residing in 14,577 ZIP codes throughout the United States were included. Overall, 5.7% of women had a preterm birth. In fully adjusted generalized estimation equation models, compared to women in the lowest quartile of area-level deprivation, odds of preterm birth increased by 9.6% among women in the second highest quartile (odds ratio (OR) 1.096; 95% confidence interval (CI) 1.021, 1.176), by 11.3% in the third highest quartile (OR 1.113; 95% CI 1.035, 1.195), and by 24.9% in the highest quartile (OR 1.249; 95% CI 1.165, 1.339). Hypertension and infection moderately mediated this association.


Even among commercially-insured women, area-level deprivation was associated with increased risk of preterm birth. Similar to individual socioeconomic status, area-level deprivation does not have a threshold effect. Implementation of policies to reduce area-level deprivation, and the screening and treatment of maternal mediators may be associated with a lower risk of preterm birth.


Area-level deprivation; Commercially-insured; Mediating pathways; Preterm birth

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