Preterm Birth in The United States The Impact of Stressful

RESEARCH AND PRACTICE
Preterm Birth in the United States: The Impact of Stressful

Life Events Prior to Conception and Maternal Age
Whitney P. Witt, PhD, MPH, Erika R. Cheng, PhD, MPA, Lauren E. Wisk, PhD, Kristin Litzelman, PhD, Debanjana Chatterjee, MA, Kara Mandell, MA,
and Fathima Wakeel, PhD, MPH
Preterm birth occurs in approximately 12% of

all births in the United States.1 Preterm birth is
a leading cause of neonatal death in the United
States2 and contributes substantially to childhood and adult morbidity and mortality.3---6
Reducing the prevalence of preterm birth has
signicant implications for the future health
and well-being of children and families and
accordingly is a national health priority7 and the
focus of numerous public health efforts. However,
despite extensive research, practice, and policy
devoted to reducing the number of children born
preterm, the prevalence of preterm birth in the
United States remains unacceptably high, suggesting that additional risk factors must be identied for outcomes to improve.
Maternal exposure to stress during pregnancy is an important contributor to preterm
birth, primarily through the neuroendocrine,
immune, and inammatory processes.8,9 In
addition, European population-based evidence
has suggested that exposure to stressors before
pregnancy (i.e., severe life events such as
death or serious illness of a relative) may also
be associated with preterm birth.10 However, to
our knowledge, no study has investigated the
independent effects of events prior to conception and during pregnancy that are critical for
isolating the effects of stress at these different
time periods. A study by Khashan et al.11
examined these periods as mutually exclusive
categories compared with an unexposed
group. Specically, women were recorded as
having a stressful life event: (1) before pregnancy,
(2) during the rst trimester, (3) during the second
trimester, or (4) during the third trimester.
Women who experienced a stressful life event in
more than 1 time period were categorized into 1
of these groups on the basis of this a priori
hierarchy. Similarly, in a study by Class et al.12
women who experienced both preconception and
prenatal stress were removed from analyses.
In addition, a well-known U-shaped relationship exists between maternal age and the
Objectives. We determined whether and to what extent a womans exposure

to stressful life events prior to conception (PSLEs) was associated with preterm
birth and whether maternal age modified this relationship.
Methods. We examined 9350 mothers and infants participating in the first
wave of the Early Childhood Longitudinal Study, Birth Cohort, a nationally
representative sample of US women and children born in 2001, to investigate the
impact of PSLEs on preterm birth in the United States. We estimated the effect of
exposure on preterm birth with weighted logistic regression, adjusting for maternal
sociodemographic and health factors and stress during pregnancy.
Results. Of the women examined, 10.9% had a preterm birth. In adjusted
analyses, women aged 15 to 19 years who experienced any PSLE had over a 4-fold
increased risk for having a preterm birth. This association differed on the basis of
the timing of the PSLE.
Conclusions. Findings suggest that adolescence may be a sensitive period for
the risk of preterm birth among adolescents exposed to PSLEs. Clinical, programmatic, and policy interventions should address upstream PSLEs, especially for
adolescents, to reduce the prevalence of preterm birth and improve maternal and
child health. (Am J Public Health. 2014;104:S73S80. doi:10.2105/AJPH.2013.
301688)
risk of preterm birth, such that adolescents
and older women have a higher risk.13---15
However, whether this effect varies by
womens exposure to stress is not known.
We capitalized on population-based data
available from the Early Childhood Longitudinal
Study, Birth Cohort (ECLS-B), to accomplish 2
specic aims. First, we sought to determine
whether and to what extent a womans exposure
to stressful life events prior to conception (PSLEs)
was associated with experiencing a preterm birth.
Second, we sought to identify whether the association between PSLEs and preterm birth was
modied by maternal age. Findings from this
national study provide critical evidence
about preconception predictors of preterm birth
and therefore have signicant implications for
approaches to preconception, interconception,
and primary care, as well as for policy and
programmatic efforts to improve birth outcomes.
METHODS
Data were from the rst wave of the ECLS-B,
a nationally representative cohort of children
Supplement 1, 2014, Vol 104, No. S1 | American Journal of Public Health
born in 2001 and their parents. The ECLS-B

used a clustered, list frame design to select
a nationally representative probability sample
of the approximately 4 million children born in
2001, with oversampling of children from
minority groups (specically, Chinese, other
Asian/Pacic Islander, American Indian, and
Alaska Native), twins, and children born with
very low and low birth weights.16 Children
born to mothers younger than 15 years, those
who were adopted after their birth certicates
were issued, and those who did not survive
until 9 months of age were excluded from the
sampling frame.17 Registered births were sampled within primary sampling units (counties or
groups of contiguous counties) from the National Center for Health Statistics vital statistics
system. More than 14 000 births were sampled
and contacted; from these sampled births, the
nal study cohort (consisting of completed
9-month interviews) of 10 700 was formed
when the children were aged approximately
9 months.
We obtained restricted data for this study by
permission and with approval from the
Witt et al. | Peer Reviewed | Research and Practice | S73
Institute for Education Sciences Data Security

Ofce of the US Department of Education,
National Center for Education Statistics. In
accordance with center guidelines, all reported
unweighted sample sizes were rounded to the
nearest 50.16
Participants were eligible for this study if
the main survey respondent was the infants
biological mother (n = 10 550); we subsequently excluded an additional 450 records
with missing birth certicate data. The ECLS-B
included individual records for each child
within twin pairs identied through oversampling; for this analysis, we randomly selected
1 twin from each pair to retain in the sample.
For other multiples in the sample (i.e., not explicitly recruited as part of the oversampling), only
1 infant from the household was surveyed. Our
nal sample contained 9350 mother---child dyads.
Measures
The rst wave of the study occurred when
the child was aged approximately 9 months.
Data were collected from the infants birth
certicate, computer-assisted personal interviews, and parental self-administered questionnaires.
Preterm birth. We categorized the childs
gestational age at birth (reported on the
birth certicate in clinical weeks) as preterm
(< 37 weeks gestation) and term ( 37 weeks
gestation).
Stressful life events prior to conception. We
derived the date of conception using information from the birth certicate on the length of
gestation and date of birth of the index child.
We coded women as having experienced a
PSLE if they indicated that 1 or more of the
following events occurred prior to conception:
1.
2.
3.
4.
5.
6.
7.
death of the respondents mother,

death of the respondents father,
death of a previous live-born child,
divorce,
separation from partner,
death of a spouse, or
fertility problems.
All of these experiences are considered stressful life events or have been operationalized as
such in previous research.18---21 Death of a previous live-born child was collected from birth
certicate data and was assumed to have
occurred prior to conception. To examine this

assumption, we tested alternate specications of
our PSLE measure, with death of a child removed
and with death of a child included as a pregnancy
event. These modications did not substantially
change our ndings; therefore, we present the
results from the model including death of a child
as a PSLE.
Prenatal health and stress. We used data
from the birth certicate to determine
whether women had experienced any of the
following pregnancy complications: anemia,
diabetes, oligohydramnios or hydramnios,
hypertension during pregnancy, eclampsia or
preeclampsia, incompetent cervix, Rh sensitization, uterine bleeding, premature rupture
of membranes, placental abruption, or placenta previa. Birth certicate data were from
the 1989 revision of the US Standard Certicate of Live Birth (see http://www.cdc.
gov/nchs/data/techap99.pdf).
We also used data from the birth certicate
to determine whether women had previously
given birth to a preterm or small for gestational
age (SGA) infant and to identify women with
chronic conditions, including cardiac disease,
lung disease, genital herpes, hemoglobinopathy, chronic hypertension, renal disease, or
other medical risk factors. We calculated prepregnancy body mass index (BMI; dened as
weight in kilograms divided by height in meters
squared) from the respondents measured
height and self-report of weight prior to pregnancy (< 18.5 kg/m2 [underweight], 18.5--24.9 kg/m2 [normal], 25---29.9 kg/m2 [overweight], 30 kg/m2 [obese], and unknown).22
In addition, we evaluated timing of initiation of
prenatal care (in the rst trimester, in the
second or third trimester, or did not receive
prenatal care), whether the index child was
a singleton or multiple birth, and parity (data
from the birth certicate, coded as number of
prior live births: 0, 1, or 2). Finally, we
coded women as having experienced a stressful life event during pregnancy if they indicated
that 1 or more of the following events occurred
during their pregnancy:
1.
2.
3.
4.
5.
S74 | Research and Practice | Peer Reviewed | Witt et al.
death of the respondents mother,

death of the respondents father,
divorce,
separation from partner, or
death of a spouse.
Maternal sociodemographic factors. Maternal

sociodemographic factors included race/
ethnicity (White [non-Hispanic], Black [nonHispanic], Asian/Pacic Islander [nonHispanic], Hispanic, or other race [nonHispanic]), age (15---19, 20---24, 25---29,
30---34, or 35 years), marital status at the
infants birth (married or living with partner;
separated, divorced, or widowed; or never
married), health insurance coverage during
pregnancy (no health insurance, any publicly
funded insurance, or private health insurance
coverage only), US region of residence
(Northeast, Midwest, South, or West),23 and
socioeconomic status (SES). We dened SES
using a 5-category composite index (quintiles) generated by the National Center for
Education Statistics that incorporated:
1.
2.
3.
4.
fathers or male guardians education,

mothers or female guardians education,
fathers or male guardians occupation,
mothers or female guardians occupation,
and
5. household income.16
Statistical Analyses
We conducted analyses using survey procedures from SAS version 9.2 (SAS Institute,
Cary, NC). We corrected the standard errors
for clustering within strata and the primary
sampling unit and used applied survey weights
to produce estimates that account for the
complex survey design, unequal probabilities
of selection, and survey nonresponse. All results are based on weighted counts.
We generated summary statistics to describe
the sample characteristics and used the v2 test
to determine signicant differences in sociodemographic characteristics between women
who did and did not experience any PSLE and
by infant term status.
We used staged multivariate logistic regression models to examine the impact of exposure
to PSLEs on the infants term status. Model 1
adjusted for exposure to any stressful life event
during pregnancy, maternal chronic conditions,
having a prior preterm or SGA baby, prepregnancy BMI, initiation of prenatal care, plurality,
parity, maternal age, maternal race/ethnicity,
marital status at birth, health insurance coverage, SES, and region of residence; model 2
added pregnancy complications. We estimated
American Journal of Public Health | Supplement 1, 2014, Vol 104, No. S1
adjusted odds ratios (AORs) and 95% condence intervals (CIs) comparing the term status
of infants born to women exposed and not
exposed to PSLEs from the multivariate
models. In addition, we tested the models with
multiples removed from the sample; because
this did not inuence our ndings, we present
results from the full sample.
Given the established U-shaped relationship
between age and term status,13---15 we initially
chose to examine the interaction between
continuous maternal age and PSLEs with
a quadratic functional form (P = .038). However, we present the relationship with categorical age for ease of interpretation.
Sensitivity analyses examined the effect of
exposure to PSLEs on infant term status within
3 nonmutually exclusive time frames: PSLEs
that occurred (1) within 1 year prior to conception, (2) 1 year or more prior to conception,
and (3) prior to conception without a denite
time window.
RESULTS
Of mothers, 19.7% experienced any PSLE
(Table 1). Mean length of gestation was 38.8
weeks; 10.9% of women delivered a preterm
infant (Table 2). Exposure to PSLEs was more
common among women with preterm infants
than among women with term infants (preterm,
24.2%; term, 19.2%; P < .01). Compared with
mothers of children born at term, mothers of
children born preterm were more likely to have
experienced a pregnancy complication or
a chronic condition or to have had a prior
preterm or SGA baby; they were also more
likely to deliver multiples, to initiate prenatal
care after the rst trimester, and to be Black
(Non-Hispanic), never married, publicly insured, or of low SES. Mothers who gave birth to
a preterm infant were more likely to be
adolescents (aged 15---19 years) and less likely
to be aged 25 to 29 years than were mothers
who gave birth to a term infant.
Adjusted analyses revealed a statistically
signicant interaction between any PSLEs and
continuous age (P = .038; data not shown).
When we examined this interaction categorically, we found that the effect of PSLEs on
preterm birth was strongest for women aged
15 to 19 years (AOR = 4.32; 95% CI = 1.48,
12.61), and this effect diminished as women
increased in age (Figure 1; Table 3). Women

aged 35 years and older had higher odds of
delivering a preterm infant than did women
aged 25 to 29 years, regardless of their
exposure to PSLEs (Table 3). Pregnancy complications were signicantly and independently
associated with increased odds of preterm birth
(AOR = 2.33; 95% CI = 1.93, 2.82). In the
fully adjusted model, having a prior child born
preterm or SGA, delivering multiples, Black
(non-Hispanic) race, Hispanic ethnicity, and
low SES were signicantly associated with
increased odds of having a preterm birth
(Appendix A, available as a supplement to the
online version of this article at http://www.
ajph.org).
When we examined the timing of womens
exposure to PSLEs, we found that the interaction between PSLEs and younger age (15---19
years) was observed for events occurring within
1 year prior to conception (AOR = 10.97; 95%
CI = 1.93, 62.21; data not shown). Women who
were exposed to any PSLEs 1 year or more prior
to conception and were aged 20 to 24 or 30
years or older also had greater risk of preterm
birth than did women aged 25 to 29 years
without such an event (for women aged 20---24
years: AOR = 1.83; 95% CI = 1.00, 3.34; for
women aged 30---34 years: AOR = 1.44; 95%
CI = 0.98, 2.12; for women aged 35 years:
AOR = 1.62; 95% CI = 1.08, 2.43; data not
shown).
TABLE 1Type and Timing of Stressful

Life Events Prior to Conception:
US Early Childhood Longitudinal Study,
Birth Cohort, 2001
Variable
Stressful life events prior to conception

None
80.3
Any stressful life event prior to conception

1 event
19.7
17.3
2 events
2.2
3 events
0.2
Type of stressful life events prior to conception

Experienced fertility problems
Never
99.6
Ever
0.4
Death of mother prior to conception

No
Yes
97.2
2.8
Death of father prior to conception

No
94.4
Yes
5.6
Death of a child
Never
Ever
Divorced prior to conception
98.8
1.2
No
89.6
Yes
10.4
Separated prior to conception

No
98.3
Yes
1.7
Widowed prior to conception
DISCUSSION
No
Yes
As the rst population-based study to our

knowledge to investigate the relationship between exposure to PSLEs and preterm birth in
the United States, this study contributes 3
signicant ndings to the literature. First, our
ndings suggest that the magnitude of the effect
of PSLEs on preterm birth varies by maternal
age. This effect heterogeneity may partially
explain the established U-shaped relationship
between maternal age and preterm birth. Second, the ndings indicate that the association
between PSLEs and preterm birth was strongest among women aged 15 to 19 years,
suggesting that adolescence may be a sensitive
period for the risk of preterm births for adolescents who have been exposed to PSLEs and
highlighting a potentially important period for
interventions aimed at reducing preterm birth.
99.8
0.2
Timing of stressful life events prior to conception

Unknown timinga
None
Any
98.1
1.9
< 1 y prior to conceptionb

None
Any
1 y prior to conceptionb
95.7
4.3
None
85.1
Any
14.9
Note. Data are weighted percentages. National Center

for Education Statistics rounding rules applied to
unweighted numbers. Weighted total: n = 3 774 441;
unweighted total: n = 9350.
a
Stressful life events for which an exact event date was not
available, including fertility problems or death of a child.
b
Stressful life events for which an exact event date was
available, including death of mother or father, divorce,
marital separation or widowed.
TABLE 2Descriptive Statistics by Maternal Stressful Life Events Prior to Conception and Preterm Birth Status:
US Early Childhood Longitudinal Study, Birth Cohort, 2001
Stressful Life Events Prior to Conception
Variable
Total weighted no. (%)
Total unweighted no.
Weeks gestation, mean (SD), median
Total
None
Any
3 774 441 (100.0)
3 029 554 (80.3)
744 887 (19.7)
9350
38.80 (2.45), 38.52
7350
38.86 (2.38), 38.56
Birth Status
P
1950
38.56 (2.70), 38.36
Preterm
Term
412 176 (10.9)
3 362 265 (89.1)
2250
.001
33.94 (4.08), 34.44
7100
39.40 (1.47), 38.74
.001
Stress and obstetric factors

Stressful life events prior to conception
None, %
Any, %
Mean (SD)
.003
80.3
19.7
0.22 (0.48)
...
...
...
...
0.00 (. . .)
1.13 (0.38)
Stressful life events during pregnancy, %
75.8
24.2
.001
0.28 (0.80)
80.8
19.2
0.22 (0.44)
.001
None
94.2
93.8
96.0
94.0
94.3
Any
5.8
6.2
4.0
6.0
5.7
74.9
87.8
25.1
12.2
73.9
80.1
26.1
19.9
97.6
99.1
2.4
0.9
Pregnancy complications, %
None
Any
86.9
84.6
13.6
13.1
15.4
Maternal chronic conditions, %

79.4
79.9
77.6
Any
20.6
20.1
22.4
.001
Prior child born preterm or SGA, %

Yes
Prepregnancy BMI, kg/m2, %
< 18.5
.001
.098
None
No
.001
.026
86.4
99.0
99.2
98.0
1.0
0.8
2.0
.001
.369
.038
3.3
3.3
3.5
4.2
3.2
18.524.9
49.5
50.2
46.7
47.1
49.8
2529.9
26.8
26.6
27.6
25.3
27.0
30
17.9
17.4
19.7
19.7
17.7
2.5
2.5
2.6
3.8
2.4
Unknown
Initiation of prenatal care, %
In the first trimester
In the second or third trimester
Did not receive prenatal care
.246
95.5
4.2
95.5
4.3
95.8
3.7
0.3
0.3
0.5
93.5
5.8
95.8
4.0
0.6
0.3
*
*
*
.001
Singleton
98.3
98.7
96.5
90.2
99.2
Multiple
1.7
1.3
3.5
9.8
0.8
.001
Parity,a %
*
.011
.001
No. of children born, %
.003
.761
.068
Nulliparous
40.7
44.7
24.5
***
39.4
40.9
Primaparous
Multiparous
32.8
26.5
32.6
22.8
33.8
41.6
***
31.0
29.6
33.0
26.1
Maternal sociodemographic factors

.001
Age, y, %
.02
1519
7.5
9.0
1.3
***
9.3
7.3
2024
24.2
27.4
11.4
***
25.2
24.1
2529
26.2
27.1
22.7
**
22.5
26.7
3034
25.0
23.7
30.1
***
23.7
25.1
35
17.1
12.9
34.4
***
19.4
16.8
*
*
Continued
TABLE 2Continued
Race/ethnicity, %
57.4
56.4
61.3
Black (non-Hispanic)
14.1
14.2
13.6
3.5
3.6
3.0
Asian/Pacific Islander (non-Hispanic)
.001
.001
White (non-Hispanic)
**
50.0
58.3
***
20.4
13.3
***
3.0
3.5
Other (non-Hispanic)
2.5
2.4
2.8
3.0
2.4
Hispanic
Marital status at delivery, %
22.6
23.4
19.3
**
.001
23.6
22.5
Married or living with partner
83.4
82.9
85.5
78.0
84.1
Separated, divorced, widowed
3.1
2.5
5.3
***
3.9
2.9
13.5
14.6
9.2
***
18.0
13.0
Never married
Health insurance status, %
.001
***
***
.001
.008
Private only
59.1
58.2
62.9
***
51.8
60.0
***
Any public
37.4
38.4
33.5
**
45.4
36.5
***
None
Socioeconomic status, %
3.4
3.4
3.5
2.8
3.5
First quintile (lowest)
19.7
20.6
15.8
24.7
19.1
Second quintile
20.0
20.1
19.7
21.4
19.8
.001
.001
Third quintile
20.1
19.6
21.8
Fourth quintile
20.2
19.4
23.1
Fifth quintile (highest)
20.1
20.2
19.7
Region of residence, %
***
19.3
20.1
19.1
20.3
15.6
20.6
.208
***
***
.520
Northeast
Midwest
17.1
22.3
17.3
22.4
16.2
21.7
15.9
22.4
17.2
22.2
South
36.9
36.2
39.6
39.5
36.6
West
23.8
24.1
22.5
22.1
24.0
Note. BMI = body mass index; SGA = small for gestational age. Preterm defined as < 37-wk gestation; term defined as 37-wk gestation. National Center for Educational Statistics rounding rules
applied to unweighted numbers; unweighted subgroup numbers may not add to the total because of rounding error.
a
Parity of the mother not including her most recent live birth.
*P < .05; **P < .01; ***P < .001.
Finally, we found that racial and ethnic disparities in preterm birth persisted even after
accounting for PSLEs and a host of covariates,
informing future research regarding racial/
ethnic disparities in preterm birth. Overall,
these novel ndings have signicant implications for research, policy, and practice surrounding the risk of preterm birth in the United
States.
Our ndings are consistent with previous
research showing a U-shaped relationship between maternal age and risk of preterm birth
such that adolescents and older women have
a higher risk.13---15 Though this relationship is
well established, the pathways by which it
occurs remain equivocal.24 Other studies have
found that stressful life events during and
before pregnancy have been associated with
preterm birth.25,26 However, to our knowledge, we are the rst to investigate whether the
relationship between exposure to PSLEs and

preterm birth varied by maternal age. More
important, in the adjusted model we did not
nd evidence to support the persistence of
a U-shaped relationship between maternal age
and risk of preterm birth in the absence of
PSLEs; instead, only women older than 35
years displayed higher odds of preterm birth,
compared with women aged 25---29 years. We
did, however, observe the U-shaped relationship among women with any exposure to
PSLEs. Because previous studies adjusting for
various sociodemographic factors have failed
to explain the mechanisms leading to this U
shape, we suggest that adolescent exposure to
PSLEs may account for a large portion of the
established increased risk of preterm birth
among adolescent mothers.
On a molecular level, younger women may
be more vulnerable to the pathophysiological
repercussions of exposure to severe PSLEs

because the adolescent brain has been shown
to have a heightened response to stress. Specically, adolescents tend to experience an
overactivation of their stress hormone receptors, such as dopamine, serotonin, and adrenaline.27,28 Additionally, on a macro level,
expectations and available personal resources
may partly explain why younger mothers are
more susceptible to PSLEs. Because death of
a parent was the most frequently experienced
PSLE for women aged 15 to 19 years, such an
unexpected event may be particularly traumatic for younger women,29 whereas the increased likelihood, and thus anticipation, of
parental death as women age may lessen the
negative psychopathological toll of such an
event. Moreover, because adolescent mothers
may be more emotionally and nancially reliant on their parents30 or partners (separation
No stressful life events prior to conception
Any stressful life events prior to conception
32%
Prevalence
28%
24%
20%
Age, y
None, %
1519
12.9
Any, %
31.8
2024
11.0
15.3
2529
8.7
12.5
3034
9.7
12.7
35
11.8
13.3
16%
12%
8%
1519 y
2024 y
2529 y
3034 y
35 y
Maternal Age
Adjusted OR (95% CI)
b
10
0.1
3.85
1.34
1.24
1.05
0.94
(1.28, 11.60)
(0.89, 2.02)
(0.82, 1.87)
(0.74, 1.48)
(0.65, 1.36)
1519 y
2024 y
2529 y
3034 y
35 y
Maternal Age
Note. CI = confidence interval. In panel a, the inset table displays the values of the prevalence estimates used to generate
that panel, also stratified by maternal exposure to PSLEs and maternal age at delivery. Note that the adjusted odds ratios do
not share a common reference category for the exposure; each odds ratio represents the association between exposure to
stressful life events and preterm status within each of the 5 maternal age categories (e.g., the first odds ratio, 3.85, can be
interpreted as the adjusted odds of preterm birth associated with exposure to stressful life events among women aged 1519
years at delivery, and the last odds ratio, 0.94, can be interpreted as the adjusted odds of preterm birth associated with
exposure to stressful life events among women aged 35 years).
FIGURE 1Preterm birth by maternal age and exposure to stressful life events prior to
conception, by (a) unadjusted prevalence of preterm birth and (b) adjusted odds ratios for
preterm birth: US Early Childhood Longitudinal Study, Birth Cohort, 2001.
from a partner was the next most common
event among these women) than older women,
losing a parent or partner may substantially
lessen their available resources, thereby encumbering their ability to cope with traumatic
experiences and intensifying the adverse reaction to such stressors.
Interestingly, the effect of PSLEs among
women aged 15 to 19 years was substantially
heightened when the exposure occurred within
1 year prior to conception; women aged 20 to
24 years who were exposed to PSLEs a year or
more prior to conception also had increased
odds of preterm birth. Taken together with
literature on adverse childhood events and
childhood disadvantage,31,32 these results suggest that adolescence and early adulthood may
be a particularly sensitive period that has
implications for reproductive health. Although
based on a small number of exposed cases (e.g.,
women aged 15 to 19 years with a PSLE in the
year prior to conception), these results provide
compelling evidence of the potential importance of PSLEs, and the timing of PSLEs, among
adolescent and young adult women. It is encouraging that, because the magnitude of this
effect was less for older women, over time
women may be able to rebound from negative
events experienced in adolescence. More research is warranted that adopts a life course
approach and investigates adolescence as a sensitive period for the effect of PSLEs on the
occurrence of preterm birth. Such future research
is necessary to pinpoint new avenues for public
health efforts to improve birth outcomes.
Although we found that PSLEs were associated with an increased risk of preterm birth
among adolescent mothers, this association did
not explain existing racial disparities in preterm
birth. Racial disparities in preterm birth rates
in the United States have been well documented, with Black women experiencing preterm birth at much higher rates than White
women.1 Some studies have suggested that
stress may be a contributor to racial disparities
in preterm birth through a weathering effect,
in which exposure to chronic and acute stress
among Black women across the life course
is posited to lead to more rapid biological
aging.14,25,33 Among the nationally representative sample used in this study, though, race
remained an important risk factor for preterm
birth even after controlling for stressful life
events prior to and during pregnancy. This
nding should, however, be interpreted
cautiously. Specically, the ECLS-B collected
limited data about stressful life events, and the
included events may be less salient for Black
and other minority mothers who may be less
likely to be married and more likely to experience poverty-related stressors. A more culturally appropriate measure of PSLEs may yield
different results, and future work is needed to
replicate our ndings.
Limitations
Several potential limitations should be considered when interpreting our results. First,
children who died before 9 months of age were
not eligible to participate in the ECLS-B. Our
study, therefore, likely excluded children with
the worst birth outcomes (e.g., stillbirth, neonatal death), a potential survival bias leading to
conservative estimates of the effect of PSLEs on
preterm birth. Second, birth certicate data
may underreport or incorrectly report some
information (e.g., pregnancy complications).1
However, underreporting these data would
bias our results toward the null, leading to
conservative estimates. Similarly, we relied on
self-reported data for factors such as prepregnancy BMI, which may have biased our estimates in an unknown direction. The ECLS-B
experienced a PSLE. Along these lines, pediatricians and obstetricians---gynecologists should

strive to administer preconception care to
women across the life course in an effort to
improve obstetric outcomes. For these recommendations to be fully realized, though,
changes are needed across multiple domains in
clinical practice, public health support, and
health care coverage to provide appropriate
services for women and adolescents and to
overcome barriers to preconception care delivery (e.g., fragmented provision of services,
lack of available treatment services, inadequate
reimbursement of risk assessment, and health
promotion services).43 Future work is needed
to examine the effectiveness of preconception
womens health services on improving birth
outcomes and subsequent child health outcomes over the life course.
TABLE 3Staged Multivariable Logistic Regression Models Predicting Preterm Birth: US

Early Childhood Longitudinal Study, Birth Cohort, 2001
Adjusted Odds of Preterm Birtha (< 37 Wk Gestation)
Variable
Model 1, AOR (95% CI)
Model 2, AOR (95% CI)
1519 y
1.15 (0.82, 1.61)
1.12 (0.79, 1.60)
2024 y
1.08 (0.86, 1.36)
1.07 (0.85, 1.34)
2529 y (Ref)
3034 y
1.00
1.28 (0.97, 1.69)
1.00
1.24 (0.94, 1.65)
35 y
1.66 (1.23, 2.23)
1.59 (1.18, 2.14)
No stressful life events prior to conception
Any stressful life events prior to conception

1519 y
3.83 (1.29, 11.36)
4.32 (1.48, 12.61)
2024 y
1.45 (0.98, 2.14)
1.43 (0.97, 2.11)
2529 y
1.29 (0.87, 1.92)
1.24 (0.82, 1.87)
3034 y
1.35 (0.95, 1.92)
1.30 (0.91, 1.85)
1.59 (1.08, 2.34)
1.49 (1.02, 2.18)
35 y
Stressful life events during pregnancy
None (Ref)
1.00
1.00
Any
0.79 (0.53, 1.17)
0.77 (0.52, 1.16)
Conclusions
Pregnancy complications
None (Ref)
1.00
Any
2.33 (1.93, 2.82)
Note. AOR = adjusted odds ratio; CI = confidence interval. Models also control for maternal chronic conditions, having a prior
preterm or small-for-gestational-age baby, prepregnancy body mass index, initiation of prenatal care, plurality, parity,
maternal race/ethnicity, marital status, health insurance coverage, socioeconomic status, and region of residence. Full
regression models are available in the Appendix (available as a supplement to the online version of this article at http://www.
ajph.org). All models account for complex sampling design of the Early Childhood Longitudinal Study, Birth Cohort.
a
Versus term.
collected limited data on stressful life events;

failing to capture additional events may have
resulted in misclassication. Moreover, the
number of individuals who endorsed specic
events was small; therefore, we were not able
to conduct analyses examining the independent effect of each type of event (e.g., death of
a spouse or partner) on preterm birth. Finally,
our operationalization of PSLEs may not have
comprehensively captured the spectrum of
stressors that some women experience.34---38
The results from this and other studies
investigating the role of PSLEs for obstetric
outcomes26,39 advocate for increased attention
to more upstream factors, such as stress and
stressors, to combat downstream outcomes
such as preterm birth. Moreover, treating stress
and stressors as public health problems in and
of themselves may be an effective way to
prevent multiple adverse obstetric outcomes
simultaneously. Similarly, because stress has
been implicated as a risk factor for many
other public health concerns, including cardiovascular disease40 and all-cause mortality,41
providing individuals with the resources to
cope with stress may help prevent multiple
poor health outcomes across the life course.
More importantly, our ndings have salient
implications for clinical practice. First, clinical
interventions designed to improve birth outcomes may be most effective if administered
before pregnancy. The preconception period is
increasingly being acknowledged as an important area for womens health, and strategies to
reduce general mental distress and improve
health behaviors, for example, have been recognized as important avenues for womens
preconception health care.42 Future research
should test whether screening and counseling
women of reproductive age about stress is
associated with reductions in preterm birth.
Second, ndings from this study also emphasize the importance of providing care to pregnant adolescents, especially those who have
In this national, population-based study,

adolsecents who were exposed to any PSLE had
over a 4-fold increased risk for having a preterm
birth. This nding suggests that adolescence
may be a sensitive period for the risk of preterm
birth for adolescents who have been exposed to
PSLEs. Although much remains to be learned
about the mechanisms underlying this relationship, our results indicate that clinical, programmatic, and policy interventions may need to
address upstream stressful life events prior to
conception, especially for adolescents, to reduce
the prevalence of preterm birth and improve
maternal and child health. j
About the Authors

At the time of the study, Whitney P. Witt, Erika R. Cheng,
Lauren E. Wisk, Kristin Litzelman, Debanjana Chatterjee,
Kara Mandell, and Fathima Wakeel were with the Department of Population Health Sciences, University of
Wisconsin---Madison School of Medicine and Public
Health.
Correspondence should be sent to Whitney P. Witt,
PhD, MPH, Truven Health Analytics, 7700 Old Georgetown Rd, Suite 630, Bethesda, MD 20814 (e-mail:
whitneywitt@gmail.com). Reprints can be ordered at
http://www.ajph.org by clicking the Reprints link.
This article was accepted September 14, 2013.
Contributors
W. P. Witt made substantial contributions to the study
design, acquisition of data, interpretation of data, and
drafting the article; assisted with conceptualization of
variables; and was ultimately responsible for overseeing
the data analysis and article preparation. E. R. Cheng
helped with the study design, data interpretation, and
drafting of the article. L. E. Wisk assisted with the study

design, data preparation and analysis, interpretation of
data, and drafting of the article. K. Litzelman contributed
to the interpretation of the data and drafting of the
article. D. Chatterjee assisted in interpreting the study
data, summarizing study results, and editing and rening
the article and assisted with conceptualization of the
overall analytical plan. K. Mandell helped edit and rene
the article and assisted with conceptualization of the
overall analytical plan. F. Wakeel assisted with the study
design, conceptualization of variables, interpretation of
the data, and writing and editing of the article.
Acknowledgments
This work was supported in whole or in part by federal
funds from the US Department of Health and Human
Services, Health Resources and Services Administration
(grant R40MC23625; PI, W. P. W.). Additional funding
for this research was provided by a grant from the Health
Disparities Research Scholars Program to F. Wakeel
(T32HD049302; PI, G. S.).
We also thank the anonymous reviewers for their
helpful comments and suggestions.
Human Participant Protection

The University of Wisconsin---Madison Health Sciences
institutional review board considered this study exempt
from review.
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