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Association of maternal educational attainment with preterm birth and low birth weight: A systematic review and meta-analysis
Open accessAbstract
BACKGROUNDMaternal educational attainment is an important socioeconomic indicator associated with health literacy, healthcare access, and health-related behaviors.However, its association with preterm birth and low birth weight (LBW) varies across populations, educational classifications, and study settings. AIMTo determine the associations of maternal educational attainment with preterm birth and LBW. METHODSPubMed, Web of Science, EMBASE, and the Cochrane Library were searched from inception to August 6, 2026, for observational studies examining maternal education in relation to preterm birth or LBW.Study quality was assessed using the Newcastle-Ottawa Scale.Random-effects models pooled odds ratios (OR) and 95% confidence intervals (CI).Heterogeneity, subgroup analyses, leave-one-out sensitivity analyses, and potential small-study effects were evaluated.The protocol was registered in PROSPERO (CRD42024576198). RESULTSThirty-seven studies involving 30432601 births were included; 24 contributed to preterm birth analyses and 17 to LBW analyses, with four reporting both outcomes.For ≥ 12 years vs < 12 years of maternal education, higher attainment was associated with lower odds of preterm birth (OR = 0.82, 95%CI: 0.75-0.89)and LBW (OR = 0.83, 95%CI: 0.71-0.98).Heterogeneity was considerable for preterm birth (I² = 99.3%) and LBW (I² = 5 / 55 97.9%).Subgroup estimates varied by region, economic setting, and study design.Leave-one-out analyses did not materially alter the overall direction of associations. CONCLUSIONHigher maternal educational attainment was associated with lower odds of preterm birth and LBW, although substantial heterogeneity limits causal interpretation and generalizability.
Checked 2026-11-13 · 1 reference not checked yet
Overview
CoChat Summary
TL;DR
Higher maternal educational attainment was associated with lower odds of preterm birth and low birth weight in a meta-analysis of 37 observational studies. However, considerable heterogeneity and heterogeneous education definitions limit causal interpretation and generalizability.
Key findings
- Among 37 studies representing 30,432,601 births, maternal education ≥ 12 years vs < 12 years was associated with lower odds of preterm birth (OR = 0.82, 95%CI: 0.75–0.89; I² = 99.3%) and low birth weight (OR = 0.83, 95%CI: 0.71–0.98; I² = 97.9%).
- Preterm birth subgroup estimates were significant in the Americas (OR = 0.86, 95%CI: 0.75–0.98; I² = 99.7%), Asia (OR = 0.86, 95%CI: 0.76–0.97; I² = 92.8%), and Europe (OR = 0.74, 95%CI: 0.72–0.76; I² = 0.0%).
- Low birth weight subgroup estimates were significant in Europe (OR = 0.81, 95%CI: 0.79–0.84; I² = 18.2%) and developed countries (OR = 0.76, 95%CI: 0.69–0.84), but not in developing countries (OR = 1.02, 95%CI: 0.82–1.27).
- Leave-one-out analyses did not materially alter the direction or statistical interpretation of the overall pooled associations.
Methods
- Systematic review and meta-analysis of observational studies (cohort, case-control, cross-sectional) published from 2010 onward, identified from PubMed, Web of Science, EMBASE, and the Cochrane Library through August 6, 2026; protocol registered in PROSPERO (CRD42024576198).
- Thirty-seven studies were included; 24 contributed to preterm birth analyses and 17 to low birth weight analyses, with 4 reporting both outcomes.
- Random-effects models pooled odds ratios and 95% confidence intervals; heterogeneity was assessed with I² and Cochran’s Q, with subgroup analyses by region, study design, and national economic level, plus leave-one-out sensitivity analyses and Egger’s tests.
Limitations
- The paper states that all included studies were observational, so residual or unmeasured confounding cannot be excluded and causal inference is not warranted.
- The paper states that differences in maternal educational attainment classification limited comparability and precluded a definitive dose-response assessment; methodological quality varied, and substantial residual heterogeneity persisted.
- The paper states that some subgroup analyses included few studies, subgroup differences in statistical significance should not be interpreted as formal between-subgroup differences, and publication bias cannot be excluded because funnel plots and Egger’s tests had limited power.
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Figures
![Figure 2 Forest plots of the association between maternal educational attainment and preterm birth across pairwise education contrasts. The odds ratio (OR) in each panel compares the first-listed, higher education category with the second-listed, lower education category; OR < 1 indicates lower odds of preterm birth among mothers in the higher education category. A: > 16 years vs 12-16 years [pooled OR = 0.83, 95% confidence interval (CI): 0.69-0.99; I ² = 85.7%]; B: > 16 years vs 9-12 years (OR = 0.64, 95%CI: 0.50-0.82; I ² = 91.0%); C: 12-16 years vs 9-12 years (OR = 0.87, 95%CI: 0.79-0.95; I ² = 99.3%); D: 12-16 years vs 6-9 years (OR = 0.69, 95%CI: 0.61-0.78; I ² = 90.5%); E: 12-16 years vs ≤ 6 years (OR = 0.65, 95%CI: 0.44-0.96; I ² = 81.1%); F: 9-12 years vs 6-9 years (OR = 0.82, 95%CI: 0.76-0.88; I ² = 79.3%); G: 9-12 years vs ≤ 6 years (OR = 0.69, 95%CI: 0.550.86; I ² = 94.9%); H: 6-9 years vs ≤ 6 years (OR = 0.70, 95%CI: 0.53-0.92; I ² = 76.1%). Studyspecific ORs and 95%CIs are shown as squares and horizontal lines, respectively; square](/paper-figures/1b7a0511f845408aaee2fd03faab4891/association-of-maternal-educational-attainment-with-preterm-birth-and-low-birth-figure-2.png)
![Figure 3 Forest plots of the association between maternal educational attainment and low birth weight across pairwise education contrasts. The odds ratio (OR) in each panel compares the first-listed, higher education category with the second-listed, lower education category; OR < 1 indicates lower odds of low birth weight among mothers in the higher education category. A: > 12 years vs 9-12 years [pooled OR = 0.88, 95% confidence interval (CI): 0.75-1.02; I ² = 96.9%]; B: > 12 years vs 6-9 years (OR = 0.69, 95%CI: 0.60-0.80; I ² = 83.7%); C: > 12 years vs ≤ 6 years (OR = 0.75, 95%CI: 0.44-1.29; I ² = 69.5%); D: 9-12 years vs 6-9 years (OR = 0.81, 95%CI: 0.74-0.88; I ² = 83.0%); E: 9-12 years](/paper-figures/f6639b7ec9ad44429426b1a77084b190/association-of-maternal-educational-attainment-with-preterm-birth-and-low-birth-figure-3.png)
Verification
Claims the paper makes
0 Valid · 0 Not valid · 15 Not checked · 130 Own results and interpretations
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“and LBW (OR = 0.83, 95%CI: 0.71-0.98).”
- Also stated in: § Subgroup and sensitivity analyses · plain
“the overall pooled analysis likewise showed lower odds among mothers with ≥ 12 years of education than among those with < 12 years of education (OR = 0.83, 95%CI: 0.71-0.98)”
§ Association of maternal educational attainment with preterm birth and low birth weight: A systematic review and meta-analysis > Abstract
plainstates an association- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Also stated in: § Subgroup and sensitivity analyses · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For ≥ 12 years vs < 12 years of maternal education, higher attainment was associated with lower odds of preterm birth (OR = 0.82, 95%CI: 0.75-0.89)”
- Also stated in: § Subgroup and sensitivity analyses · plain
“maternal educational attainment ≥ 12 years was associated with lower odds of preterm birth compared with < 12 years of education in the overall analysis (OR = 0.82, 95%CI: 0.75-0.89)”
§ Association of maternal educational attainment with preterm birth and low birth weight: A systematic review and meta-analysis > Abstract
plainstates an association- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Also stated in: § Subgroup and sensitivity analyses · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“with considerable heterogeneity (I² = 97.9%)”
§ Association of maternal educational attainment with preterm birth and low birth weight: A systematic review and meta-analysis > Subgroup and sensitivity analyses
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Subgroup estimates varied by region, economic setting, and study design.”
§ Association of maternal educational attainment with preterm birth and low birth weight: A systematic review and meta-analysis > Abstract
plainstates an association- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Leave-one-out analyses did not materially alter the overall direction of associations.”
- Also stated in: § Subgroup and sensitivity analyses · plain
“Exclusion of individual studies did not materially alter the direction or statistical interpretation of the overall pooled associations”
§ Association of maternal educational attainment with preterm birth and low birth weight: A systematic review and meta-analysis > Abstract
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Also stated in: § Subgroup and sensitivity analyses · plain
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Citations
Cites
Measuring inconsistency in meta-analyses
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Meta-analysis in clinical trials
DerSimonian, R., & Laird, N. (1986) · Controlled Clinical Trials · doi:10.1016/0197-2456(86)90046-2 · Cited by 39,552
The combination of estimates from different experiments
Cochran, W. G. (1954) · Biometrics · doi:10.2307/3001666 · Cited by 5,380
Chawanpaiboon, S., Vogel, J. P., Moller, A.-B., Lumbiganon, P., Petzold, M., Hogan, D., Landoulsi, S., Jampathong, N., Kongwattanakul, K., Laopaiboon, M., et al. (2019) · The Lancet Global Health · doi:10.1016/s2214-109x(18)30451-0 · Cited by 2,572
Blencowe, H., Krasevec, J., de Onis, M., Black, R. E., An, X., Stevens, G. A., Borghi, E., Hayashi, C., Estevez, D., Cegolon, L., et al. (2019) · The Lancet Global Health · doi:10.1016/s2214-109x(18)30565-5 · Cited by 1,242
Maternal and neonatal factors related to prematurity
de Oliveira, L. L., Gonçalves, A. D. C., da Costa, J. S. D., & Bonilha, A. L. D. L. (2016) · Revista da Escola de Enfermagem da USP · doi:10.1590/s0080-623420160000400002 · Cited by 124
Association of Health Literacy Among Nulliparous Individuals and Maternal and Neonatal Outcomes
Yee, L. M., Silver, R. M., Haas, D. M., Parry, S. I., Mercer, B. M., Wing, D. A., Reddy, U. M., Saade, G. R., Simhan, H. N., & Grobman, W. A. (2021) · JAMA Network Open · doi:10.1001/jamanetworkopen.2021.22576 · Cited by 85
Gurung, A., Wrammert, J., Sunny, A. K., Gurung, R., Rana, N., Basaula, Y. N., Paudel, P., Pokhrel, A., & Ashish, K. C. (2020) · Archives of Public Health · doi:10.1186/s13690-020-00446-7 · Cited by 79
Rogne, T., Gill, D., Liew, Z., Shi, X., Stensrud, V. H., Nilsen, T. I. L., & Burgess, S. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2023.51166 · Cited by 72
Income Inequality, Parental Socioeconomic Status, and Birth Outcomes in Japan
Fujiwara, T., Ito, J., & Kawachi, I. I. (2013) · American Journal of Epidemiology · doi:10.1093/aje/kws355 · Cited by 69
Research works printed but not linked: 2
- Hu XL, Chen Y, Xia HP, Zhang YJ. [Analysis of maternal clinical risk factors for different degrees of small for gestational age infant]. Shanghai Jiaotong Daxue Xuebao (Yixueban) 2020; 40: 489-493 [DOI: 10.3969/j.issn.1674-8115.2020.04.012] · DOI
- Zhang X, Zhou M, Chen L, Hao B, Zhao G. Risk factors for preterm birth: a case- control study in rural area of western China. Int J Clin Exp Med 2015; 8: 4527-4532 [PMID: 26064379]
Cited by
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Metadata
- Authors
- Tian, Y.-G., Huang, S.-F., Jin, D.-F., Li, S.-L., Sun, J.-K., Wang, P., Li, Z.-P., Fan, Y.-W., Chen, S.-S., & Zhang, C.-J.
- Affiliations
- Fifth Affiliated Hospital of Zhengzhou University (CN)
- Venue
- World Journal of Meta-Analysis
- Publisher
- Baishideng Publishing Group Inc.
- Published
- 2026-10-08
- ISSN
- 2308-3840 (ISSN-L)
- OpenAlex
- W7220896472
- Cited by
- 0
- References
- 48
- FWCI
- 0.00
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Licence
- cc-by-nc
- Locations
- World Journal of Meta-Analysis (publishedVersion, cc-by-nc)
- 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
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Birth, Development, and Health
- Keywords
- maternal educational attainment, preterm birth, low birth weight, socioeconomic status, maternal education, birth outcomes, health literacy, health care access
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