Highlight
- Preterm birth is linked to a modest increase in risk for not completing high school and obtaining a university degree.
- Sociodemographic factors such as sex, maternal education, socioeconomic status, and migration status have a larger influence on educational attainment than prematurity.
- The association between gestational age and educational outcomes demonstrates a dose-response pattern, with extremely preterm individuals at highest risk.
- Early interventions and long-term support systems are critical to improve educational trajectories in preterm-born individuals and their families.
Study Background and Disease Burden
Preterm birth, defined as birth before 37 weeks of gestation, represents a significant public health issue worldwide, accounting for approximately 10% of live births globally. Advances in neonatal care have increased survival rates for preterm infants, including those born extremely preterm (<28 weeks). Nevertheless, preterm birth is associated with neurodevelopmental complications that can manifest as cognitive, behavioral, and academic challenges persisting into adulthood. Despite recognition of these neurodevelopmental sequelae, large-scale population data elucidating the long-term educational outcomes of individuals born preterm remain scarce. Understanding how prematurity interacts with social determinants is critical for informing interventions and policies aimed at mitigating adverse educational trajectories and optimizing life-course outcomes for this growing population.
Study Design
This case-control study analyzed a comprehensive birth cohort from Quebec, Canada, encompassing individuals born between 1976 and 1995. The cohort included all infants born preterm—categorized as extremely preterm (<28 weeks), very preterm (28 to <32 weeks), and moderate-to-late preterm (32 to <37 weeks)—matched in a 1:2 ratio with term-born controls (37 to 42 weeks gestation). Controls were matched by birth year, sex, and pregnancy type (singleton or twins). Data were longitudinally obtained through administrative databases linking birth records with educational outcomes from the Quebec Ministry of Education and death registries, allowing follow-up to age 43 years. Individuals who died before 2019 or lacking education records were excluded to ensure data completeness and longitudinal accuracy.
Exposure variables focused on preterm birth categories by gestational age. Sociodemographic variables, including sex, maternal education level, socioeconomic status (derived using postal codes and the Material and Social Deprivation Index), and migration status were extracted to assess their relative contributions. Primary educational outcomes included final high school grade average, high school graduation status by age 22, and university degree attainment at any age.
Key Findings
A total of 297,820 participants were analyzed, including 95,745 individuals born preterm (0.6% extremely preterm, 4.4% very preterm, 27.9% moderate-to-late preterm) and 199,575 full-term controls. Males constituted 54.0% of the cohort, and 9.4% had mothers born outside Canada.
Among individuals who remained in school, the association between preterm birth status and final high school grade average was negligible, suggesting that preterm birth per se did not significantly impair academic performance in those continuing education. However, when assessing educational attainment, a clear dose-response relationship emerged between gestational age and likelihood of completing high school or obtaining a university degree.
Specifically, individuals born extremely preterm had an 80% higher odds of not graduating high school by age 22 (odds ratio [OR], 1.80; 99% confidence interval [CI], 1.54–2.09) and a 68% higher odds of not obtaining a university degree at any age (OR, 1.68; 99% CI, 1.39–2.02) compared with term-born peers. Those born very preterm and moderate-to-late preterm exhibited intermediate risks consistent with a gradation by gestational age.
Importantly, when adjusting for sociodemographic variables, the relative contribution of preterm birth to educational outcomes was smaller than factors such as male sex, lower maternal education, socioeconomic deprivation, and maternal migration status. For example, male sex and lower maternal education had stronger predictive associations with not completing high school or university attenuating the independent effect of prematurity.
Collectively, these findings highlight that while biological vulnerability conferred by preterm birth impacts long-term educational attainment, the broader social context exerts a predominant influence. This underscores a multifactorial etiology underlying disparities in educational achievement.
Expert Commentary
This landmark population-based study by Loose et al. provides robust evidence quantifying the interplay between preterm birth and social determinants in shaping long-term educational outcomes. The well-powered design and extensive follow-up to mid-adulthood offer insights rarely available in pediatric research. While prematurity remains a risk factor for lower educational attainment, addressing modifiable socioeconomic barriers may yield greater impact to improve outcomes.
Mechanistically, neurodevelopmental impairments associated with preterm birth—such as disrupted brain maturation and white matter injury—likely contribute to cognitive and learning difficulties. Yet social deprivation may compound these challenges through limited access to resources, educational support, and stable environments. The study suggests that targeted supportive interventions, early developmental surveillance, and inclusive educational policies are essential.
Study limitations include the historical cohort encompassing births from 1976 to 1995, when neonatal care differed from contemporary practices. Thus, ongoing cohorts will be necessary to evaluate trends as neonatal survival and neurodevelopmental care evolve. Additionally, although Quebec’s population-based data affords generalizability to similar high-income settings, findings warrant confirmation in diverse global contexts.
Conclusion
In conclusion, individuals born preterm, particularly at extremely low gestational ages, are at increased risk of not completing high school and university education. However, sociodemographic factors such as sex, maternal education, socioeconomic status, and migration background exert a more substantial influence on educational attainment than prematurity alone. These findings call for comprehensive, long-term follow-up and support that integrate biological and social dimensions.
Optimizing educational outcomes for individuals born preterm requires multidisciplinary strategies spanning neonatal care improvements, early childhood development programs, family-centered psychosocial support, and equitable educational access. Future research should focus on contemporary birth cohorts and investigate effective interventions to bridge the gap in educational disparities driven by prematurity and social disadvantage.
References
Loose T, Collet O, Nuyt AM, Goulet-Pelletier JC, Worrell FC, Côté S, Luu TM. Long-Term Educational Outcomes of Individuals Born Preterm. JAMA Netw Open. 2025 Oct 1;8(10):e2534918. doi: 10.1001/jamanetworkopen.2025.34918. PMID: 41032299.
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Hack M, Taylor HG, Drotar D, et al. Chronic conditions, functional limitations, and special health care needs of school-aged children born with extremely low-birth-weight in the 1990s. JAMA. 2005;294(3):318–325.