{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,26]],"date-time":"2026-03-26T16:04:18Z","timestamp":1774541058973,"version":"3.50.1"},"reference-count":51,"publisher":"American Medical Association (AMA)","issue":"3","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"\n Importance<\/jats:title>\n US territory nativity and\/or residence may be associated with health because it affects environmental exposures, insurance coverage, prenatal care, and other factors. Investigations of preterm birth in the US territories are limited.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To assess the association between maternal territory status and preterm birth, as well as whether insurance type modified associations.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n Cross-sectional study of restricted-use birth certificates of in-hospital, singleton births in the US and territories from 2014 to 2023.<\/jats:p>\n <\/jats:sec>\n \n Exposures<\/jats:title>\n Maternal territory status was defined for births in territories where data were available (Guam, Northern Mariana Islands, Puerto Rico, and Virgin Islands) for the following groups: (1) those with territory nativity and residence; (2) those with territory nativity and mainland residence; (3) those with mainland nativity and territory residence; and (4) those with mainland nativity and residence (reference group). Insurance type (private, Medicaid, or other) was evaluated as well.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n Preterm birth (live birth before 37 weeks\u2019 gestation).<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n Among 28\u202f627\u202f700 births, 465\u202f291 (1.6%) had any maternal territory status (nativity or residence). This group had a mean (SD) age of 27.1 (6.0) years, and 297\u202f593 (64.0%) had Medicaid insurance. The highest preterm birth rate was among those with territory nativity and residence (10.5%; 95% CI, 10.4%-10.7%); the lowest was among those with mainland nativity and residence (8.4%; 95% CI, 8.4%-8.5%). Individuals with territory nativity and residence had an adjusted relative risk (aRR) of 1.30 (95% CI, 1.29-1.32) for preterm birth compared with the reference group. There was significant interaction between territory residence and insurance. Compared with individuals with mainland residence and private insurance, those with territory residence and Medicaid had the highest preterm birth risk (aRR, 1.57; 95% CI, 1.55-1.59), followed by territory residence and private insurance (aRR, 1.42; 95% CI, 1.39-1.45).<\/jats:p>\n <\/jats:sec>\n \n Conclusions and relevance<\/jats:title>\n In this cross-sectional study, maternal territory nativity and residence were associated with preterm birth. Territory residence was associated with a higher risk of preterm birth, regardless of insurance type. Privately insured-individuals in US territories had a higher risk of preterm birth than Medicaid-insured individuals in the mainland. Given differential access to health care, health insurance, and other social exposures between territory and mainland populations, future work should explore causal effects and related policies that may improve birth outcomes in US territories.<\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2026.3601","type":"journal-article","created":{"date-parts":[[2026,3,26]],"date-time":"2026-03-26T15:30:41Z","timestamp":1774539041000},"page":"e263601","source":"Crossref","is-referenced-by-count":0,"title":["Maternal Nativity and Residence in US Territories and Preterm Birth"],"prefix":"10.1001","volume":"9","author":[{"given":"Diana","family":"Montoya-Williams","sequence":"first","affiliation":[{"name":"Division of Neonatology, Children\u2019s Hospital of Philadelphia, Philadelphia, Pennsylvania"},{"name":"Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia"},{"name":"Children\u2019s Hospital of Philadelphia PolicyLab, Philadelphia, Pennsylvania"},{"name":"Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alejandra","family":"Barreto","sequence":"additional","affiliation":[{"name":"Division of Neonatology, Children\u2019s Hospital of Philadelphia, Philadelphia, Pennsylvania"},{"name":"Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania"},{"name":"Now with Yale University School of Medicine, New Haven, Connecticut"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Brielle","family":"Formanowski","sequence":"additional","affiliation":[{"name":"Division of Neonatology, Children\u2019s Hospital of Philadelphia, Philadelphia, Pennsylvania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Heather H.","family":"Burris","sequence":"additional","affiliation":[{"name":"Division of Neonatology, Children\u2019s Hospital of Philadelphia, Philadelphia, Pennsylvania"},{"name":"Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia"},{"name":"Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania"},{"name":"Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia"},{"name":"Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sara C.","family":"Handley","sequence":"additional","affiliation":[{"name":"Division of Neonatology, Children\u2019s Hospital of Philadelphia, Philadelphia, Pennsylvania"},{"name":"Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia"},{"name":"Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Timothy","family":"Nelin","sequence":"additional","affiliation":[{"name":"Division of Neonatology, Children\u2019s Hospital of Philadelphia, Philadelphia, Pennsylvania"},{"name":"Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Scott A.","family":"Lorch","sequence":"additional","affiliation":[{"name":"Division of Neonatology, Children\u2019s Hospital of Philadelphia, Philadelphia, Pennsylvania"},{"name":"Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia"},{"name":"Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robin","family":"Ortiz","sequence":"additional","affiliation":[{"name":"New York University Grossman School of Medicine, Departments of Pediatrics and Population Health"},{"name":"New York University Langone Health Institute for Excellence in Health Equity"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"10","published-online":{"date-parts":[[2026,3,26]]},"reference":[{"issue":"5","key":"zoi260145r1","doi-asserted-by":"publisher","first-page":"358","DOI":"10.18043\/ncm.73.5.358","article-title":"Educational attainment as a social determinant of health.","volume":"73","author":"Telfair","year":"2012","journal-title":"N C Med J"},{"issue":"4","key":"zoi260145r2","doi-asserted-by":"publisher","first-page":"285","DOI":"10.1111\/phn.12212","article-title":"Institutional racism as a critical social determinant of health.","volume":"32","author":"Ramaswamy","year":"2015","journal-title":"Public Health Nurs"},{"issue":"Pt B","key":"zoi260145r3","doi-asserted-by":"publisher","first-page":"199","DOI":"10.1016\/j.canep.2017.08.005","article-title":"Cancer in Guam and Hawaii: a comparison of two U.S. island populations.","volume":"50","author":"Hernandez","year":"2017","journal-title":"Cancer Epidemiol"},{"issue":"5","key":"zoi260145r4","doi-asserted-by":"publisher","first-page":"394","DOI":"10.1590\/S1020-49892009000500003","article-title":"Cancer disparities between mainland and island Puerto Ricans.","volume":"25","author":"Ho","year":"2009","journal-title":"Rev Panam Salud Publica"},{"key":"zoi260145r5","doi-asserted-by":"publisher","first-page":"1605","DOI":"10.4054\/DemRes.2018.38.52","article-title":"Sociocultural variability in the Latino population: age patterns and differences in morbidity among older US adults.","volume":"38","author":"Garcia","year":"2018","journal-title":"Demogr Res"},{"issue":"17","key":"zoi260145r6","doi-asserted-by":"publisher","first-page":"1528","DOI":"10.1001\/archinternmed.2011.284","article-title":"Quality of care in the US territories.","volume":"171","author":"Nunez-Smith","year":"2011","journal-title":"Arch Intern Med"},{"issue":"42","key":"zoi260145r7","first-page":"1012","article-title":"Infant health among Puerto Ricans\u2013Puerto Rico and U.S. mainland, 1989-2000.","volume":"52","author":"Centers for Disease Control and Prevention (CDC)","year":"2003","journal-title":"MMWR Morb Mortal Wkly Rep"},{"issue":"4","key":"zoi260145r8","doi-asserted-by":"publisher","first-page":"351","DOI":"10.1007\/s10995-006-0072-4","article-title":"Selective migration and infant mortality among Puerto Ricans.","volume":"10","author":"Landale","year":"2006","journal-title":"Matern Child Health J"},{"issue":"1","key":"zoi260145r9","doi-asserted-by":"publisher","first-page":"90","DOI":"10.1007\/s10995-013-1238-5","article-title":"Racial\/Ethnic and nativity differences in birth outcomes among mothers in New York City: the role of social ties and social support.","volume":"18","author":"Almeida","year":"2014","journal-title":"Matern Child Health J"},{"issue":"1","key":"zoi260145r10","doi-asserted-by":"publisher","first-page":"65","DOI":"10.1001\/jamapediatrics.2023.4907","article-title":"Maternal nativity and preterm birth.","volume":"178","author":"Huang","year":"2024","journal-title":"JAMA Pediatr"},{"issue":"8","key":"zoi260145r12","doi-asserted-by":"publisher","DOI":"10.1016\/j.semperi.2022.151658","article-title":"Nativity and perinatal outcome disparities in the United States: beyond the immigrant paradox.","volume":"46","author":"Montoya-Williams","year":"2022","journal-title":"Semin Perinatol"},{"issue":"3","key":"zoi260145r13","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2024.3194","article-title":"Preterm birth risk and maternal nativity, ethnicity, and race.","volume":"7","author":"Barreto","year":"2024","journal-title":"JAMA Netw Open"},{"issue":"12","key":"zoi260145r14","doi-asserted-by":"publisher","first-page":"1028","DOI":"10.1111\/j.1525-1497.2003.20807.x","article-title":"Racial and ethnic disparities in cancer screening: the importance of foreign birth as a barrier to care.","volume":"18","author":"Goel","year":"2003","journal-title":"J Gen Intern Med"},{"issue":"1","key":"zoi260145r15","doi-asserted-by":"publisher","first-page":"16","DOI":"10.1080\/19485565.2021.2016368","article-title":"Disparities in diabetes between US-born and foreign-born population: using three diabetes indicators.","volume":"67","author":"Choi","year":"2022","journal-title":"Biodemography Soc Biol"},{"issue":"6","key":"zoi260145r16","doi-asserted-by":"publisher","first-page":"841","DOI":"10.1007\/s11606-007-0163-y","article-title":"Association between length of residence and cardiovascular disease risk factors among an ethnically diverse group of United States immigrants.","volume":"22","author":"Koya","year":"2007","journal-title":"J Gen Intern Med"},{"issue":"6","key":"zoi260145r17","doi-asserted-by":"publisher","first-page":"823","DOI":"10.1097\/PHH.0000000000001938","article-title":"Local public health strategies for addressing social determinants of health-analysis of recent community health improvement plans.","volume":"30","author":"Johnson","year":"2024","journal-title":"J Public Health Manag Pract"},{"issue":"12","key":"zoi260145r18","doi-asserted-by":"publisher","first-page":"1345","DOI":"10.1001\/jamapediatrics.2024.4267","article-title":"State social expenditures and preterm birth and low birth weight in the US.","volume":"178","author":"Chang","year":"2024","journal-title":"JAMA Pediatr"},{"issue":"4","key":"zoi260145r19","doi-asserted-by":"publisher","first-page":"E305","DOI":"10.1001\/amajethics.2022.305","article-title":"How is colonialism a sociostructural determinant of health in Puerto Rico?","volume":"24","author":"P\u00e9rez Ramos","year":"2022","journal-title":"AMA J Ethics"},{"key":"zoi260145r20","doi-asserted-by":"publisher","author":"Sonderlund","journal-title":"SSM-Popul Health","DOI":"10.1016\/j.ssmph.2022.101225"},{"issue":"4","key":"zoi260145r21","doi-asserted-by":"publisher","first-page":"1069","DOI":"10.1093\/bjsw\/bcz097","article-title":"Island nation, US territory and contested space: territorial status as a social determinant of indigenous health in Guam.","volume":"50","author":"Diaz","year":"2020","journal-title":"Br J Soc Work"},{"issue":"2","key":"zoi260145r22","doi-asserted-by":"publisher","first-page":"279","DOI":"10.1111\/birt.12411","article-title":"Trends and state variations in out-of-hospital births in the United States, 2004-2017.","volume":"46","author":"MacDorman","year":"2019","journal-title":"Birth"},{"issue":"9606","key":"zoi260145r23","doi-asserted-by":"publisher","first-page":"75","DOI":"10.1016\/S0140-6736(08)60074-4","article-title":"Epidemiology and causes of preterm birth.","volume":"371","author":"Goldenberg","year":"2008","journal-title":"Lancet"},{"issue":"1","key":"zoi260145r24","first-page":"1","article-title":"Births: final data for 2021.","volume":"72","author":"Osterman","year":"2023","journal-title":"Natl Vital Stat Rep"},{"issue":"1","key":"zoi260145r25","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0191002","article-title":"Effect of maternal age on the risk of preterm birth: a large cohort study.","volume":"13","author":"Fuchs","year":"2018","journal-title":"PLoS One"},{"issue":"6","key":"zoi260145r26","doi-asserted-by":"publisher","first-page":"838","DOI":"10.3390\/jcm8060838","article-title":"Influence of the adequacy of the prenatal care utilization index on small-for-gestational-age infants and preterm births in the United States.","volume":"8","author":"Shin","year":"2019","journal-title":"J Clin Med"},{"issue":"8","key":"zoi260145r27","doi-asserted-by":"publisher","first-page":"918","DOI":"10.1177\/1933719114556486","article-title":"Smoking and preterm birth.","volume":"22","author":"Ion","year":"2015","journal-title":"Reprod Sci"},{"issue":"3","key":"zoi260145r28","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0228743","article-title":"Impact of diabetes, obesity and hypertension on preterm birth: population-based study.","volume":"15","author":"Berger","year":"2020","journal-title":"PLoS One"},{"issue":"5","key":"zoi260145r29","doi-asserted-by":"publisher","first-page":"675","DOI":"10.1016\/j.amepre.2019.07.007","article-title":"Black-White disparities in preterm birth: geographic, social, and health determinants.","volume":"57","author":"Thoma","year":"2019","journal-title":"Am J Prev Med"},{"issue":"21","key":"zoi260145r30","doi-asserted-by":"publisher","first-page":"2165","DOI":"10.1056\/NEJMsa065029","article-title":"Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants.","volume":"356","author":"Phibbs","year":"2007","journal-title":"N Engl J Med"},{"issue":"11","key":"zoi260145r31","doi-asserted-by":"publisher","first-page":"1265","DOI":"10.1503\/cmaj.110977","article-title":"Missing covariate data in clinical research: when and when not to use the missing-indicator method for analysis.","volume":"184","author":"Groenwold","year":"2012","journal-title":"CMAJ"},{"issue":"1","key":"zoi260145r32","doi-asserted-by":"publisher","first-page":"79","DOI":"10.2105\/AJPH.92.1.79","article-title":"Incomplete birth certificates: a risk marker for infant mortality.","volume":"92","author":"Gould","year":"2002","journal-title":"Am J Public Health"},{"issue":"3","key":"zoi260145r33","doi-asserted-by":"publisher","first-page":"509","DOI":"10.1111\/aman.13601","article-title":"Nonsovereign racecraft: how colonialism, debt, and disaster are transforming Puerto Rican racial subjectivities.","volume":"123","author":"Godreau","year":"2021","journal-title":"Am Anthropol"},{"issue":"5","key":"zoi260145r34","doi-asserted-by":"publisher","first-page":"308","DOI":"10.1053\/j.semperi.2019.03.021","article-title":"Challenges in classification and assignment of causes of stillbirths in low- and lower middle-income countries.","volume":"43","author":"Patterson","year":"2019","journal-title":"Semin Perinatol"},{"issue":"9","key":"zoi260145r35","doi-asserted-by":"publisher","first-page":"1013","DOI":"10.1002\/hec.4116","article-title":"Preconception subsidized insurance: prenatal care and birth outcomes by race\/ethnicity.","volume":"29","author":"Palmer","year":"2020","journal-title":"Health Econ"},{"issue":"1","key":"zoi260145r36","doi-asserted-by":"publisher","first-page":"34","DOI":"10.1016\/S0749-3797(18)30498-7","article-title":"Pregnancy outcomes of U.S.-born Puerto Ricans: the role of maternal nativity status.","volume":"11","author":"Engel","year":"1995","journal-title":"Am J Prev Med"},{"issue":"1","key":"zoi260145r37","doi-asserted-by":"publisher","first-page":"75","DOI":"10.2105\/AJPH.2024.307867","article-title":"Adding nativity, citizenship, and immigration status to health monitoring and survey data.","volume":"115","author":"Marouf","year":"2025","journal-title":"Am J Public Health"},{"issue":"6","key":"zoi260145r38","doi-asserted-by":"publisher","first-page":"586","DOI":"10.1080\/13557858.2013.814763","article-title":"Contextualizing nativity status, Latino social ties, and ethnic enclaves: an examination of the \u2018immigrant social ties hypothesis\u2019.","volume":"18","author":"Viruell-Fuentes","year":"2013","journal-title":"Ethn Health"},{"issue":"3","key":"zoi260145r39","article-title":"Voting rights denied by residency: enfranchising millions of U.S.Citizens in U.S. territories.","volume":"19","author":"Borgonia","year":"2021","journal-title":"Seattle J Soc Justice"},{"issue":"17","key":"zoi260145r40","doi-asserted-by":"publisher","first-page":"1579","DOI":"10.1001\/archinternmed.2011.305","article-title":"Understanding health care disparities in the US territories.","volume":"171","author":"Gutierrez","year":"2011","journal-title":"Arch Intern Med"},{"issue":"1","key":"zoi260145r43","doi-asserted-by":"publisher","DOI":"10.1001\/jamahealthforum.2022.5541","article-title":"Maternity care deserts in the US.","volume":"4","author":"Sonenberg","year":"2023","journal-title":"JAMA Health Forum"},{"key":"zoi260145r44","doi-asserted-by":"publisher","year":"2025","journal-title":"AJPM Focus","DOI":"10.1016\/j.focus.2025.100362"},{"issue":"9","key":"zoi260145r49","doi-asserted-by":"publisher","DOI":"10.1001\/jamahealthforum.2023.3088","article-title":"A call to increase health data availability in US territories-not too small to count.","volume":"4","author":"Marie McSorley","year":"2023","journal-title":"JAMA Health Forum"},{"issue":"1-2","key":"zoi260145r50","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1080\/13557859998164","article-title":"Adverse birth outcomes among Mexican-Americans: are US-born women at greater risk than Mexico-born women?","volume":"4","author":"Crump","year":"1999","journal-title":"Ethn Health"},{"issue":"5","key":"zoi260145r51","doi-asserted-by":"publisher","first-page":"1095","DOI":"10.1007\/s10903-018-0813-7","article-title":"Impact of immigration and duration of residence in US on length of gestation among black women in Newark, New Jersey.","volume":"21","author":"Elsayed","year":"2019","journal-title":"J Immigr Minor Health"},{"key":"zoi260145r11","unstructured":"Britton? ML. Boricuas, barrios and birth outcomes: residential segregation and preterm birth among Puerto Ricans in the United States. Centro Journal. 2015;27(1):70-99."},{"key":"zoi260145r41","unstructured":"Center for Medicaid and CHIP Services. 2024 Medicaid and CHIP beneficiaries at a glance:maternal health. May 2024. Accessed February 13, 2026. https:\/\/www.medicaid.gov\/medicaid\/benefits\/downloads\/2024-maternal-health-at-a-glance.pdf"},{"key":"zoi260145r42","unstructured":"Stolyar? L, Rudowitz? R. Medicaid financing and the U.S. territories: implications of the Build Back Better Act. KFF. February 9, 2022. Accessed July 2, 2024. https:\/\/www.kff.org\/policy-watch\/medicaid-financing-and-u-s-territories-implications-build-back-better-act\/"},{"key":"zoi260145r45","unstructured":"U.S. Department of Health and Human Services. III.A.1. Program Overview\u2014Northern Mariana Islands\u20142024. 2024. Accessed February 13, 2026. https:\/\/mchb.tvisdata.hrsa.gov\/Narratives\/ExecutiveSummary\/726aa275-170d-4d3d-83ce-0a7d432e7602"},{"key":"zoi260145r46","unstructured":"CareerMD. Governor Juan F. Luis Hospital and Medical Center. Accessed June 19, 2025. https:\/\/app.careermd.com\/physicians\/careerfairs\/employersnapshot.aspx?pid=244447075&utm"},{"key":"zoi260145r47","unstructured":"University of Puerto Rico School of Medicine. Department of pediatrics, neonatology section. Neonatology. Accessed June 19, 2025. https:\/\/md.rcm.upr.edu\/pediatrics\/neonatology\/"},{"key":"zoi260145r48","unstructured":"Kime? P. The military on Guam has no intensive care unit for newborns in critical condition. Some don\u2019t make it. Military.com. June 18, 2024. Accessed August 2, 2024. https:\/\/www.military.com\/daily-news\/2024\/06\/18\/guam-lacks-newborn-intensive-care-unit-potentially-putting-hundreds-of-babies-born-troops-each-year.html"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2846956\/montoyawilliams_2026_oi_260145_1773945481.81008.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,26]],"date-time":"2026-03-26T15:30:45Z","timestamp":1774539045000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2846956"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,26]]},"references-count":51,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2026,3,2]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2026.3601","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,26]]}}}