A Cross-Sectional Analysis of Racial Equity and Preterm Birth Across U.S. Metropolitan Areas

Preterm birth is a pressing public health issue, with short- and long-term implications for newborns, their families, and society. Although studies are increasingly examining the structural determinants of this birth outcome, few have considered the role of regional equity—residents’ access to resources, opportunity, and power within a region. This study merges U.S. birth certificate data (2023) with a metropolitan-level Racial Equity Index generated by the National Equity Atlas project to investigate the overall and race-specific associations between racial equity, including its constituent measures of prosperity and inclusion, and preterm birth. Multivariable logistic regression models were fit for the overall sample (N = 2,359,347) and stratified by race. Regional prosperity reduced the odds of preterm birth, but the effect of racial inclusion depended on whether it was measured as past or current performance. Combining past inclusion with current prosperity resulted in 4% lower odds of preterm birth. The results provide some support for proponents who emphasize the importance of historic legacies of exclusion, but they also suggest that attention should extend to regional growth and prosperity since those set the basis for the resources to distribute more equitably. Addressing preterm birth will require sustained commitment to both closing racial gaps and ensuring shared prosperity.