A Secondary Analysis of Race/Ethnicity and other Maternal Factors Affecting Adverse Birth Outcomes in San Bernardino County

Objectives Though it is the largest county in the lower United States, minimal attention has been given to the elevated rates of poor perinatal outcomes and infant mortality in San Bernardino County. This study sought to analyze adverse birth outcomes such as low birth weight, and infant mortality as an outcome of specific proxy maternal sociodemographic factors. Methods Data from the California Department of Health Services Office of Vital Statistics birth cohort of mothers delivering between 1999 and 2001 (N = 1,590,876 participants) were analyzed. Of those, 5.5% (n = 86,736) were births in San Bernardino County. Low birth weight, very low birth weight, death in infants less than one year of age, and other maternal sociodemographic factors were explored. All events of low birth weight and deaths among infants less than one year of age were used as significant variables in statistical models. Results Black mothers experienced more than twice the rate of very low birth weight (3.89) than their White counterparts (1.39). The most significant contributors to adverse birth outcomes among Black women were length of gestation and maternal education, whereas the most significant predictor of infant mortality was birth weight. Conclusions This study demonstrates that traditional risk factors such as length of gestation and maternal age only partially explain adverse birth outcomes. These findings highlight the need to advocate for the systematic collection of data on maternal education and length gestation and for the promotion of public health initiatives that address these inequities in our most vulnerable of populations.     

Contrasting socioeconomic gradients in small for gestational age and preterm birth in Argentina, 2003–2007

Objectives

To examine the socioeconomic gradients in birth outcomes among singleton infants in Argentina, 2003–2007.

Methods

We analyzed data of 3,230,031 singleton infants born in 2003–2007, obtained from vital statistics. Associations between birth outcomes [small for gestational age (SGA), low birth weight (LBW), and preterm birth (PTB)] and socioeconomic indicators (maternal education and area-based material deprivation quintiles) were assessed with logistic regression.

Results

The risk of SGA increased with higher socioeconomic disadvantage, but that of PTB decreased. Compared to mothers who attained a tertiary or university degree, mothers who did not complete primary school were more likely to have a SGA infant [adjusted OR (95 % CI): 1.65 (1.62, 1.68)], but less likely to deliver preterm [0.92 (0.90, 0.94)]. As a result of the conflicting trends in SGA and PTB, LBW exhibited inconsistent socioeconomic gradients.

Conclusions

The excess risk of adverse birth outcomes associated with socioeconomic disadvantage was consistently reflected by SGA, but not by LBW and PTB. These findings challenge the usefulness of LBW as an indicator population health. Further research is needed to explain the reverse socioeconomic gradients in PTB.     

Maternal smoking during pregnancy and anthropometric measurements of newborns: a population-based study in southern of Brazil

This cross-sectional study aimed to investigate the prevalence of maternal smoking during pregnancy and its impact on anthropometric measurements of newborns. A standardized questionnaire was applied to all pregnant women admitted for delivery in the maternity units in Rio Grande, Rio Grande do Sul State, Brazil, in 2007. Measurements were taken of the newborns' weight, length, and head circumference. Prevalence rates were 23% for maternal smoking during pregnancy and 29% for exposure to environmental tobacco smoke. After adjusting for potential confounding factors, compared with those whose mothers never smoked, newborns whose mothers smoked throughout pregnancy showed average decreases of 223.4 g in birth weight (95%CI: 156.7;290.0), 0.94 cm in birth length (95%CI: 0.60;1.28), and 0.69 cm in head circumference (95%CI: 0.42-0.95). In conclusion, prevalence of maternal smoking during pregnancy was high in this municipality. Maternal smoking during pregnancy was inversely associated with birth weight, length, and head circumference.     

Estimated Number of Preterm Births and Low Birth Weight Children Born in the United States Due to Maternal Binge Drinking

The objective of this study was to estimate the aggregate burden of maternal binge drinking on preterm birth (PTB) and low birth weight (LBW) across American sociodemographic groups in 2008. To estimate the aggregate burden of maternal binge drinking on preterm birth (PTB) and low birth weight (LBW) across American sociodemographic groups in 2008. A simulation model was developed to estimate the number of PTB and LBW cases due to maternal binge drinking. Data inputs for the model included number of births and rates of preterm and LBW from the National Center for Health Statistics; female population by childbearing age groups from the U.S. Census; increased relative risks of preterm and LBW deliveries due to maternal binge drinking extracted from the literature; and adjusted prevalence of binge drinking among pregnant women estimated in a multivariate logistic regression model using Behavioral Risk Factor Surveillance System survey. The most conservative estimates attributed maternal binge drinking to 8,701 (95 % CI: 7,804–9,598) PTBs (1.75 % of all PTBs) and 5,627 (95 % CI 5,121–6,133) LBW deliveries in 2008, with 3,708 (95 % CI: 3,375–4,041) cases of both PTB and LBW. The estimated rate of PTB due to maternal binge drinking was 1.57 % among all PTBs to White women, 0.69 % among Black women, 3.31 % among Hispanic women, and 2.35 % among other races. Compared to other age groups, women ages 40–44 had the highest adjusted binge drinking rate and highest PTB rate due to maternal binge drinking (4.33 %). Maternal binge drinking contributed significantly to PTB and LBW differentially across sociodemographic groups.     

Prenatal and intrapartum events and sudden infant death syndrome

The purpose of this study was to evaluate specific pregnancy and labour and delivery events that may increase the risk of sudden infant death syndrome (SIDS). A matched case-control study was conducted in five counties in southern California, using California death certificate records. The sample consisted of 239 Caucasian, African-American, Hispanic and Asian mothers of SIDS infants and 239 mothers of control infants matched on sex, race, birth hospital and date of birth. Mothers participated in a detailed telephone interview and provided access to obstetric and paediatric records. More case than control mothers reported a family history of anaemia (OR=2.12, P < 0.001). Placental abruptions were strongly associated with SIDS (unadjusted OR=7.94, [95% CI 1.34,47.12]). There was an increased risk of SIDS death associated with maternal anaemia during pregnancy (OR=2.51, [95% CI 1.25,5.03]), while simultaneously adjusting for maternal smoking during pregnancy, maternal years of education and age, parity, infant birthweight, gestational age, medical conditions at birth, infant sleep position and post-natal smoking. Interactions of anaemia and prenatal smoking as well as anaemia and post-natal smoking were not statistically significant. There were no other statistically significant differences between case and control mothers for pregnancy conditions, labour and delivery events (e.g. caesarean sections, anaesthesia, forceps) or newborn complications (e.g. nuchal cord, meconium aspiration). Anaemia and placental abruptions were significantly associated with an increased risk of SIDS; both are circumstances in which a fetus may become hypoxic, thereby compromising the subsequent growth, development and ultimate survival of the infant.     

Characteristics of preterm delivery and low birthweight among 113,994 infants in Alberta: 1994-1996

This study examined the impact of infant and maternal factors on preterm delivery and low birthweight (LBW) in Alberta between January 1, 1994 and December 31, 1996. Data on 113,994 births were collected from vital statistics registration birth data. Logistic regression models for preterm and LBW delivery suggested the key risk factors were multiple and still birth (odds ratios > 22.0). Other characteristics included female gender, birth defects, nulliparous women, maternal age 35 and greater, unmarried, history of abortion, maternal smoking, maternal street drug use, and having less than 4 prenatal visits (odds ratios 0.86-2.54). Interactions between smoking and alcohol, and smoking and parity were noted. Efforts to improve the currently low rates (8.2%) of smoking cessation during pregnancy are required. Social, economic and medical factors associated with delayed childbearing and birth outcomes should be investigated.     

Is Maternal Smoking during Early Pregnancy a Risk Factor for All Low Birth Weight Infants?

Background

Low birth weight (LBW) infants do not form a homogeneous group; LBW can be caused by prematurity or poor fetal growth manifesting as small for gestational age (SGA) infants or intrauterine growth retardation. We aimed to clarify the relationship of maternal smoking with both SGA and preterm LBW infants.

Methods

The study population comprised pregnant women who registered at the Koshu City between January 1, 1995, and December 31, 2000, and their children. We performed multivariate analyses using multiple logistic regression models to clarify the relationship of maternal smoking during pregnancy with the SGA outcome and preterm birth in LBW infants.

Results

In this study period, 1,329 pregnant women responded to questionnaires, and infant data were collected from 1,100 mothers (follow-up rate: 82.8%). The number of LBW infants was 81 (7.4%). In this cohort, maternal smoking during early pregnancy was associated with LBW and the SGA outcome. Maternal smoking during early pregnancy was a risk factor for LBW with SGA outcome and for LBW with full-term birth. However, it was not a risk factor for LBW with appropriate weight for gestational age (AGA) and LBW with preterm birth.

Conclusion

These results suggested that LBW with AGA and LBW with preterm birth were associated with other risk factors that were not considered in this study, such as periodontal disease. For the prevention of LBW, not only abstinence from smoking during pregnancy but also other methods such as establishing a clinical setting should be adopted.Key words: Infant, Low Birth Weight; Pregnancy; Risk Factors; Smoking     

Association of Maternal Medical Conditions and Unfavorable Birth Outcomes: Findings from the 1996–2003 Mississippi Linked Birth and Death Data

This study aimed to identify factors contributing to high rates of preterm birth (PTB), low birth weight (LBW) and infant mortality in Mississippi while considering both traditional risk factors and maternal medical conditions. The retrospective cohort study used 1996–2003 Mississippi linked birth and infant death files. Multiple logistic regression was used to investigate association between maternal medical conditions and unfavorable birth outcomes. Along with traditional risk factors, hypertension was significantly associated with PTB and LBW. Women with hypertension were about 2.2 and 3.2 times as likely to have PTB and LBW, respectively. Hydramnios/oligohydramnios increased 1.8–4.4 folds of risk for PTB, LBW and infant death and was significantly associated with the unfavorable birth outcomes. Non-Hispanic black women were about 1.5–2.0 times as likely to have an unfavorable birth outcome compared to non-Hispanic white women. Maternal education and prenatal care effect appeared to be modified by maternal race. Certain maternal medical conditions may be contributing to PTB, LBW and infant mortality rates identifying preconception and prenatal healthcare as possible strategies for reducing unfavorable outcomes. Results suggest that different risk profiles for unfavorable outcomes may exist according to maternal race highlighting the need to consider racial groups separately when further exploring the sociodemographic and/or health-related factors that contribute to unfavorable birth outcomes.     

Independent and Interactive Associations of Prenatal Mood and Substance Use With Infant Birth Outcomes

The main objective of this work is to examine low prenatal mood, alcohol and tobacco use and rates of preterm (PTB) and low birth weight (LBW) births among women in Minnesota between 2002 and 2006. We examined the Minnesota version of the national, cross-sectional survey of postpartum women, the Pregnancy Risk Assessment Monitoring System (MN PRAMS). Of the 11,891 women sampled in 2002–2006, 7,457 had complete data for analysis; the weighted response rates averaged 76%. The major variables of interest were: LBW, PTB, maternal mood during pregnancy, prenatal alcohol use, prenatal tobacco use and interaction terms created from the mood and substance use variables. Women with low mood who used tobacco during pregnancy were twice as likely to have a LBW infant as women who did not smoke and reported high mood (AOR = 2.12, 95% CI: 1.35, 3.33, P = 0.001). Among women who abstained from alcohol during pregnancy, those with low mood were at an increased risk for PTB (AOR = 1.95, 95% CI: 1.54–2.45, P < 0.0001) compared to women with high mood. Low maternal mood was associated with increased risks for PTB, and LBW births among MN PRAMS respondents. Substance use and low prenatal mood co-occur and the combined effect on PTB and LBW birth outcomes warrants further investigation.     

The association between maternal influenza vaccination during pregnancy and adverse birth outcomes in the United States: Pregnancy risk Assessment Monitoring System (PRAMS)

ObjectiveInfluenza vaccination during pregnancy is highly recommended. We examined the association between maternal influenza vaccination and adverse birth outcomes.MethodsThis cross-sectional study used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) during 2012–2017. The primary exposure was the receipt of influenza vaccination during pregnancy. Low birth weight (LBW), preterm birth (PTB), and small for gestational age (SGA) were the primary outcomes. We conducted multivariable logistic regression models to estimate the adjusted odds ratios (AOR) and 95% confidence intervals (CI). Covariates used to adjust confounding included maternal age, marital status, education, race and ethnicity, insurance status before pregnancy, and smoking status. For a subgroup in 2012–2015, we analyzed the association between influenza vaccination in each trimester and adverse birth outcomes.ResultsDuring 2012–2017, compared with unvaccinated women, women vaccinated during pregnancy had a lower risk of LBW and PTB. During 2012–2015, maternal influenza vaccination in the 1st and 3rd trimesters was associated with a reduced risk of LBW and PTB, and vaccination in the 3rd trimester had a greater protective effect than in the 1st trimester. Influenza vaccination was not associated with SGA regardless of trimester.ConclusionsOur findings suggest that influenza vaccination during pregnancy is a safe and effective way to protect newborns.     

Previous Adverse Outcome of Term Pregnancy and Risk of Preterm Birth in Subsequent Pregnancy

Objective Evaluate risk of preterm birth (PTB, < 37 completed weeks’ gestation) among a population of women in their second pregnancy with previous full term birth but other adverse pregnancy outcome. Methods The sample included singleton live born infants between 2007 and 2012 in a birth cohort file maintained by the California Office of Statewide Health Planning and Development. The sample was restricted to women with two pregnancies resulting in live born infants and first birth between 39 and 42 weeks’ gestation. Logistic regression was used to calculate the risk of PTB in the second birth for women with previous adverse pregnancy outcome including: small for gestational age (SGA) infant, preeclampsia, placental abruption, or neonatal death (≤ 28 days). Risks were adjusted for maternal factors recorded for second birth. Results The sample included 133,622 women. Of the women with any previous adverse outcome, 4.7% had a PTB while just 3.0% of the women without a previous adverse outcome delivered early (relative risk adjusted for maternal factors known at delivery 1.4, 95% CI 1.3–1.5). History of an SGA infant, placental abruption, or neonatal death increased the adjusted risk of PTB in their second birth by 1.5–3.7-fold. History of preeclampsia did not elevate the risk of a preterm birth in the subsequent birth. Conclusions for Practice The findings indicate that women with previous SGA infant, placental abruption, or neonatal death, despite a term delivery, may be at increased risk of PTB in the subsequent birth. These women may be appropriate participates for future interventions aimed at reduction in PTB.

     

Smoking during pregnancy--United States, 1990-2002

Cigarette smoking during pregnancy adversely affects the health of both mother and child. The risk for adverse maternal conditions (e.g., premature rupture of membranes, abruptio placentae, and placenta previa) and poor pregnancy outcomes (e.g., neonatal mortality and stillbirth, preterm delivery, and sudden infant death syndrome) is increased by maternal smoking. Infants born to mothers who smoke weigh less than other infants, and low birthweight (<2,500 grams) is a key predictor for infant mortality. Infertility and conception delay also might be elevated by smoking. National health objectives for 2010 target an increase in cessation to 30% among pregnant smokers during the first trimester and abstinence from cigarettes by 99% of women giving birth. To assess progress toward these goals, CDC analyzed state-specific trends in maternal smoking during 1990-2002 by using data collected on birth certificates. This report summarizes the results of those analyses, which indicated that whereas participating areas observed a significant decline in maternal smoking during the surveillance period, 10 states reported recent increases in smoking by pregnant teens. Although the widespread public health message to abstain from smoking during pregnancy has helped decrease maternal smoking, to reduce prevalence further, implementation of additional interventions are required.     

Rising Disparities in Severe Adverse Birth Outcomes Among Haitians in Québec, Canada, 1981–2006

Perinatal health data for Haitians are scant. We evaluated adverse birth outcomes for Haitians in Québec, Canada. We analyzed 2,124,909 live births from 1981 to 2006. Haitian ethnicity was assessed using maternal birth country (Haiti, other Caribbean country, other foreign country, Canada) and home language (Creole, French/English but Creole mother tongue, French/English, other). Associations between ethnicity and preterm birth (PTB), low birth weight (LBW), and small-for-gestational-age (SGA) birth were calculated. Adverse birth outcomes were more common among mothers with Haitian ethnicity. Relative to Canadian-born mothers, odds for Haitian-born mothers were 4 times greater for extreme PTB (≤27 weeks), twice greater for very PTB (28–31 weeks), and 25% higher for moderate PTB (32–36 weeks). Patterns were similar for SGA birth and severe cases of LBW. Despite overall decreases LBW and SGA birth, relative and absolute inequalities increased over time. Perinatal health inequalities are increasing for Haitian-born mothers.     

Physical abuse during pregnancy and risk of low-birthweight infants among aborigines in Taiwan

OBJECTIVES: The aim of this study was to assess whether physical abuse during pregnancy is associated with an increased risk of giving birth to a low-birthweight (LBW) infant. STUDY DESIGN AND METHODS: A cross-sectional survey was conducted and 1143 aboriginal women were recruited into this study. The Abuse Assessment Screen was used to collect information regarding maternal physical abuse, and infants' birth weights were obtained from hospital medical records. Multiple logistic regression was used to estimate the association of LBW with physical abuse during pregnancy, adjusting for behavioural and sociodemographic variables. RESULTS: Of the women experiencing physical abuse during their recent pregnancy, 11.76% delivered a LBW infant, compared with 5.78% of women who did not experience physical abuse [odds ratio (OR) 1.97, 95% confidence intervals (CI) 1.07-3.63]. Physical abuse during pregnancy was also significantly associated with low weight gain in the prenatal period. Univariate analysis revealed that delivery of a LBW infant was associated with maternal alcohol use, maternal betel chewing and maternal educational level. Multiple logistic regression was performed, adjusting for prenatal weight gain, maternal height, maternal years of education, maternal alcohol use and maternal betel quid use. It was found that women who reported physical abuse with injuries during pregnancy had a 2.4-fold higher risk of delivering a LBW infant compared with women who did not report physical abuse with injuries (adjusted OR=2.43, 95%CI 1.06-5.55). CONCLUSIONS: These findings suggest that physical abuse during pregnancy is an independent risk factor for delivery of a LBW infant. Prenatal care for aboriginal women should be coupled with routine systematic screening for the presence of abuse during pregnancy, and adequate support and interventions for abused women.     

Factors affecting birth weight in Kuwait. Part II: Pregnancy characteristics and health factors.

The aim of this was to determine the mean birth weight of Kuwaiti infants, the incidence of low birth weight and the impact of maternal age, smoking, health status, parents' consanguinity and pregnancy characteristics on infants' birth weight. The study was conducted in the major maternity hospital in Kuwait where the body weight of 1995 newborn infants was recorded shortly after birth. Data describing maternal age, duration of pregnancy, sex of the infant and maternal illness during pregnancy were recorded. Mothers were interviewed to collect data on duration between present and last pregnancy, birth order of the infant, parents' consanguinity and frequency of smoking. The results show that the mean birth weight was 3.5 Kg and the incidence of low birth weight was 3.4%. The results illustrate that young mothers were more liable to have small infants while old mothers were more liable to deliver a very heavy or low birth weight infant. The weight of the newborn infant was positively correlated with duration of pregnancy, duration between present and last pregnancy and birth order. The mean birth weight of male infants (3.51 Kg) was higher than females (3.47 Kg). Parents' consanguinity and maternal smoking had a slight effect on infants' birth weight. The results show that diabetic mothers delivered large babies. On the contrary, the incidence of low birth weight was highest (7.0%) among infants of hypertensive mothers.     

Racial/Ethnic and Nativity Differences in Birth Outcomes Among Mothers in New York City: The Role of Social Ties and Social Support

Immigrants have lower rates of low birth weight (LBW) and to some extent preterm birth (PTB), than their US-born counterparts. This pattern has been termed the ‘immigrant health paradox’. Social ties and support are one proposed explanation for this phenomenon. We examined the contribution of social ties and social support to LBW and PTB by race/ethnicity and nativity among women in New York City (NYC). The NYC Pregnancy Risk Assessment Monitoring System survey (2004–2007) data, linked with the selected items from birth certificates, were used to examine LBW and PTB by race/ethnicity and nativity status and the role of social ties and social support to adverse birth outcomes using bivariate and multivariable analyses. SUDAAN software was used to adjust for complex survey design and sampling weights. US- and foreign-born Blacks had significantly increased odds of PTB [adjusted odds ratio (AOR) = 2.43, 95 % CI 1.56, 3.77 and AOR = 2.6, 95 % CI 1.66, 4.24, respectively] compared to US-born Whites. Odds of PTB among foreign-born Other Latinas, Island-born Puerto Ricans’ and foreign-born Asians’ were not significantly different from US-born Whites, while odds of PTB for foreign-born Whites were significantly lower (AOR = 0.47, 95 % CI 0.26, 0.84). US and foreign-born Blacks’ odds of LBW were 2.5 fold that of US-born Whites. Fewer social ties were associated with 32–39 % lower odds of PTB. Lower social support was associated with decreased odds of LBW (AOR 0.69, 95 % CI 0.50, 0.96). We found stronger evidence of the immigrant health paradox across racial/ethnic groups for PTB than for LBW. Results also point to the importance of accurately assessing social ties and social support during pregnancy and to considering the potential downside of social ties.     

Population attributable risk for adverse pregnancy outcomes related to smoking in adolescents and adults

BACKGROUND: Little is known about how population-attributable risks (PAR) for adverse birth outcomes due to smoking differ in adolescent and adult pregnancies. METHODS: An analysis of community and hospital-based cross-sectional studies in Liverpool was undertaken to estimate the PAR values of low birthweight (LBW), preterm birth, and small for gestational age (SGA) births resulting from pregnancy smoking covering the period between 1983 and 2003. Maternal smoking status and pregnancy outcomes were available for a sample of 12631 women. RESULTS: The prevalence of maternal pregnancy smoking was 40% in the community sample and 33% in adults and 40% among adolescent pregnancies in the hospital sample. The PAR values (95% CI) associated with LBW, preterm birth and SGA outcomes due to maternal pregnancy smoking in the community sample were 27% (25-30), 13% (11-15) and 25% (23-27), respectively. The PAR values in adults in the hospital sample were 29% (27-31) for LBW, 16% (14-19) for preterm birth and 28% (26-31) for SGA. The corresponding PAR values in adolescents were 39% (34-43), 12% (7-18) and 31% (23-40). The LBW risk attributed to pregnancy smoking in adolescents was significantly higher than for adults (P=0.05). CONCLUSION: About one-third of LBW, one-quarter of SGA and one-sixth of preterm births could be attributed to maternal smoking during pregnancy. The magnitude of the problem was greater among adolescent pregnancies, among whom a sub-group of mothers with very high risk for adverse birth outcomes due to pregnancy smoking was identified.     

Smoking Status and Factors Associated with Smoking of First-Time Mothers During Pregnancy and Postpartum: Findings from the Healthy Beginnings Trial

This study aimed to investigate smoking status and factors associated with smoking among first-time mothers and their partners during pregnancy and postpartum. A prospective cohort study with 201 first-time mothers was conducted using data from the Healthy Beginnings Trial, undertaken in one of the most socially and economically disadvantaged areas of south-western Sydney, Australia in 2007–2010. Smoking status of the mothers and their partner and smoke-free home status were assessed at 30–36 weeks of pregnancy, and also at 6, 12 and 24 months postpartum. Multivariable two-level logistic random-intercept models were conducted. Smoking rates of the first-time mothers were 17.6 % during pregnancy and 22.5 % postpartum. The likelihood of being a current smoker among the mothers significantly increased after giving birth, with an adjusted odds ratio of 3.96 (95 % CI 1.3–12.1) at 6 months, 6.19 (95 % CI 1.84–30.9) at 12 months, and 6.58 (95 % CI 1.86–23.23) at 24 months postpartum. Mothers’ smoking status was significantly inversely associated with educational level and positively associated with their partner’s smoking status. In addition, mothers who breastfed their child were significantly less likely to be a smoker, with an adjusted odds ratio of 0.10 (95 % CI 0.02–0.68). Although pregnancy may act as a motivator to quit smoking, it is of concern that maternal smoking rate increased after giving birth. Smoking cessation programs should not only focus on smoking in pregnancy, but also address other risk factors, particularly in postpartum women and their partners.     

Rurality and Birth Outcomes: Findings From Southern Appalachia and the Potential Role of Pregnancy Smoking

ABSTRACT:  Context: Rates of preterm birth (PTB) and low birth weight (LBW) vary by region, with disparities particularly evident in the Appalachian region of the South. Community conditions related to rurality likely contribute to adverse birth outcomes in this region. Purpose: This study examined associations between rurality and related community conditions, and newborn outcomes in southern Appalachia, and explored whether pregnancy smoking explained such associations. Methods: Data for all births in a southern Appalachian county over a 2-year period were extracted from hospital records. Findings: Data were available for 4,144 births, with 45 different counties of residence. Babies born to women from completely rural counties, on average, weighed 700 g less, were 1.5 inches shorter, and were born over 3 weeks earlier than less rural infants. In addition, these babies were 4.5 times more likely to be LBW, 4 times more likely to be PTB, and 5 times more likely to be admitted to the neonatal intensive care unit (NICU). Effects were also found for per capita income, poverty rate, and unemployment rate, all of which were associated with rurality. Some, but not all of the association was explained by elevated rates of pregnancy smoking. Conclusions: Babies born to women residing in rural and economically depressed counties in southern Appalachia are at substantially increased risk for poor birth outcomes. Improving these outcomes in the rural South will likely require addressing access to health services and information, health care provider retention, transportation services, employment opportunities, and availability of public health services including smoking cessation assistance.