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Mediators of socioeconomic inequalities in preterm birth: a systematic review
Open accessAbstract
Background: Rates of preterm birth are substantial with significant inequalities. Understanding the role of risk factors on the pathway from maternal socioeconomic status (SES) to preterm birth can help inform interventions and policy. This study therefore aimed to identify mediators of the relationship between maternal SES and preterm birth, assess the strength of evidence, and evaluate the quality of methods used to assess mediation. Methods: Using Scopus, Medline OVID, “Medline In Process & Other Non-Indexed Citation”, PsycINFO, and Social Science Citation Index (via Web of Science), search terms combined variations on mediation, socioeconomic status, and preterm birth. Citation and advanced Google searches supplemented this. Inclusion criteria guided screening and selection of observational studies Jan-2000 to July-2020. The metric extracted was the proportion of socioeconomic inequality in preterm birth explained by each mediator (e.g. ‘proportion eliminated’). Included studies were narratively synthesised. Results: Of 22 studies included, over one-half used cohort design. Most studies had potential measurement bias for mediators, and only two studies fully adjusted for key confounders. Eighteen studies found significant socioeconomic inequalities in preterm birth. Studies assessed six groups of potential mediators: maternal smoking; maternal mental health; maternal physical health (including body mass index (BMI)); maternal lifestyle (including alcohol consumption); healthcare; and working and environmental conditions. There was high confidence of smoking during pregnancy (most frequently examined mediator) and maternal physical health mediating inequalities in preterm birth. Significant residual inequalities frequently remained. Difference-of-coefficients between models was the most common mediation analysis approach, only six studies assessed exposure-mediator interaction, and only two considered causal assumptions. Conclusions: The substantial socioeconomic inequalities in preterm birth are only partly explained by six groups of mediators that have been studied, particularly maternal smoking in pregnancy. There is, however, a large residual direct effect of SES evident in most studies. Despite the mediation analysis approaches used limiting our ability to make causal inference, these findings highlight potential ways of intervening to reduce such inequalities. A focus on modifiable socioeconomic determinants, such as reducing poverty and educational inequality, is probably necessary to address inequalities in preterm birth, alongside action on mediating pathways.
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TL;DR
This systematic review of 22 observational studies found that socioeconomic inequalities in preterm birth are only partly explained by six groups of mediators, most consistently maternal smoking and maternal physical health. A large residual direct effect of socioeconomic status remained in most studies, and methodological limitations constrain causal inference.
Key findings
- Of 22 included studies, 18 found significant socioeconomic inequalities in preterm birth; six mediator groups were assessed: maternal smoking, mental health, physical health (including BMI), lifestyle (including alcohol), healthcare, and working/environmental conditions.
- There was high confidence that smoking during pregnancy mediates inequalities: 16 estimates of proportion eliminated ranged from 2% to 45%, with the largest study (1,390,742 singleton births) reporting 26% for extremely preterm, 33% for very preterm, and 30% for moderately preterm births.
- There was high confidence for maternal physical health as a mediator, with proportion eliminated ranging from 3% to 22% for physical health measures; evidence for mental health was mixed, and alcohol, working/environmental conditions, and healthcare had low to moderate or inconsistent evidence.
- Most studies showed a substantial residual direct effect of SES; complete mediation was unlikely by individual variables, though three studies found composites removed statistical significance for SES measures.
Methods
- Systematic review registered with PROSPERO (CRD42020203613), searching Scopus, Medline OVID, Medline In Process, PsycINFO, and Social Science Citation Index, plus citation and advanced Google searches; inclusion criteria covered observational studies from Jan 2000 to July 2020.
- After screening, 22 studies were included; data were dual-extracted, quality-assessed using a hybrid approach (risk of bias plus mediation-specific criteria), and narratively synthesised because meta-analysis was not appropriate.
- The main metric extracted was proportion eliminated; certainty of evidence was assessed considering sample size, quality score, and consistency, with a harvest plot and DAG used to display and integrate findings.
Limitations
- The review states that different SES measures are potentially not comparable, only eight studies made clear that exposure was measured before outcome, and the search focused on studies explicitly examining mediation, potentially missing extractable mediated effects.
- The review also states data limitations: some plausible mediators were not examined (e.g., air pollution, urbanicity, domestic violence), mediator measurement was often problematic, preterm birth was mostly treated as homogeneous, and many studies did not estimate confidence intervals or mediator significance.
- Evident from the text: only two studies fully adjusted for all three key confounders (maternal age, parity, race/ethnicity), only two explicitly considered causal assumptions, and only six assessed exposure-mediator interaction, limiting causal interpretation.
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“Significant residual inequalities frequently remained.”
§ Mediators of socioeconomic inequalities in preterm birth: a systematic review > Abstract > Results
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“Studies assessed six groups of potential mediators: maternal smoking; maternal mental health; maternal physical health (including body mass index (BMI)); maternal lifestyle (including alcohol consumption); healthcare; and working and environmental conditions.”
§ Mediators of socioeconomic inequalities in preterm birth: a systematic review > Abstract > Results
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“There is, however, a large residual direct effect of SES evident in most studies.”
§ Mediators of socioeconomic inequalities in preterm birth: a systematic review > Abstract > Conclusions
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“only six studies assessed exposure-mediator interaction”
- Also stated in: § Mediation approach · plain
“six studies examined exposure-mediator interaction in their analysis”
§ Mediators of socioeconomic inequalities in preterm birth: a systematic review > Abstract > Results
What the sources say
- Not checked yetcites [33] Poulsen G, Andersen AMN, Jaddoe VWV, Magnus P, Raat H, Stoltenberg C, et al. Does smoking during pregnancy mediate educational disparities in preterm delivery? Findings from three large birth cohorts. Paediatr Perinat Epidemiol. 2019;33(2):164–71. source
- Not matchedcites [37] Dooley P. Examining individual and neighborhood-level risk factors for delivering a preterm infant. Doctor of Philosophy (PhD) thesis. Cincinnati: University of Cincinnati; 2009:189.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Not checked yetcites [38] Mehra R, Shebl FM, Cunningham SD, Magriples U, Barrette E, Herrera C, et al. Area-level deprivation and preterm birth: results from a national, commercially-insured population. BMC Public Health. 2019;19(1):236. source
- Not checked yetcites [39] Meng G, Thompson ME, Hall GB. Pathways of neighbourhood-level socio-economic determinants of adverse birth outcomes. Int J Health Geogr. 2013;12(1):32. source
- Not checked yetcites [42] Nkansah-Amankra S, Luchok KJ, Hussey JR, Watkins K, Liu X. Effects of maternal stress on low birth weight and preterm birth outcomes across neighborhoods of South Carolina, 2000–2003. Matern Child Health J. 2010;14(2):215–26. source
- Not checked yetcites [44] Ahern J, Pickett KE, Selvin S, Abrams B. Preterm birth among African American and white women: a multilevel analysis of socioeconomic characteristics and cigarette smoking. J Epidemiol Community Health. 2003;57(8):606–11. source
plain- Asserted: passes — The authors put it forward as true.
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- Also stated in: § Mediation approach · plain
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In the paper
“There was high confidence of smoking during pregnancy (most frequently examined mediator) and maternal physical health mediating inequalities in preterm birth.”
§ Mediators of socioeconomic inequalities in preterm birth: a systematic review > Abstract > Results
boostedstates a cause- Asserted: passes — The authors put it forward as true.
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In the paper
§ Mediators of socioeconomic inequalities in preterm birth: a systematic review > Results > Mediation approach
“measurement of the exposure preceded that of the outcome in nine studies [35, 38, 40, 42, 46, 47, 49–51].”
§ Mediators of socioeconomic inequalities in preterm birth: a systematic review > Discussion > Limitations of the review
“Second, only eight studies made clear that the exposure was measured before the outcome, yet temporality is a requirement for causal interpretation.”
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In the paper
§ Mediators of socioeconomic inequalities in preterm birth: a systematic review > Results > Mediation approach
“The ‘difference method’ was the most frequently used approach to assess mediation (14 studies) [33, 41–53], estimating the ‘controlled direct effect’ [14]. Other approaches used product of coefficients (seven, with path analysis in five) [34–40] and, in one, structural equation modelling not specified as path analysis [54]. Only one of the studies using the difference method estimated the statistical significance of the mediating effect,”
§ Mediators of socioeconomic inequalities in preterm birth: a systematic review > Discussion > Limitations of the data
“11 studies did not estimate mediator significance (all used the difference method) [76]”
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Unravelling the respiratory health path across the lifespan for survivors of preterm birth
Simpson, S. J., Berry, C. D., Evans, D. J., Gibbons, J. T. D., Vollsæter, M., Halvorsen, T., Gruber, K. F., Lombardi, E., Stanojevic, S., Hurst, J. R., et al. (2023) · The Lancet Respiratory Medicine · doi:10.1016/s2213-2600(23)00272-2 · Cited by 86
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Metadata
- Authors
- McHale, P., Maudsley, G., Pennington, A., Schlüter, D. K., Barr, B., Paranjothy, S., & Taylor-Robinson, D.
- Affiliations
- University of Liverpool (GB)
- University of Aberdeen (GB)
- Corresponding author
- McHale, Philip
- ORCID
- Venue
- BMC Public Health
- Published
- 2022-06-07
- Volume
- 22
- Issue
- 1
- Pages
- 1134-1134
- ISSN
- 1471-2458 (ISSN-L)
- PMC
- PMC9172189
- OpenAlex
- W4281739443
- Semantic Scholar
- 2c90ab8a6c19600a35278c80b4d16a99dc4e9aef
- Cited by
- 89
- References
- 74
- Citations by year
- 2026: 27 · 2025: 21 · 2024: 21 · 2023: 16 · 2022: 3
- FWCI
- 3.46
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- BMC Public Health (publishedVersion, cc-by)
- PubMed (publishedVersion)
- PubMed Central (publishedVersion, cc-by)
- Aberdeen University Research Archive (Aberdeen University) (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- National Institute for Health and Care Research
- Medical Research Council (MR/P008577/1, MR/T00794X/1)
- Topics
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and Neonatal Healthcare
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Infant Development and Preterm Care
- Social Sciences › Health › Health disparities and outcomes
- Keywords
- preterm birth, socioeconomic disparities, maternal socioeconomic status, mediation analysis, maternal smoking, maternal mental health, maternal physical health, body mass index, alcohol consumption, health care access, working conditions, environmental factors, poverty, educational inequality
- MeSH terms
- Female, Humans, Infant, Newborn, Pregnancy, Social Class, Socioeconomic Factors, Cohort Studies, Body Mass Index, Premature Birth
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
A language model drew the claims from the paper on 2026-11-13, under version 3 of the claim definition (model deepseek-v4.1-flash, prompt extract-v3).
A second model labelled each claim on 2026-11-13 (model jev-1.13-20260917, definition revision gold-guideline-v0.2).
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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Data sources
Bibliographic data: Semantic Scholar, OpenAlex, Crossref.
Contains information from the Semantic Scholar Academic Graph Datasets, made available under the ODC Attribution License (ODC-BY 1.0).
Semantic Scholar’s data is described in: Kinney, R., et al. (2023). The Semantic Scholar Open Data Platform. arXiv:2301.10140.
