Document Type



Doctor of Philosophy (PhD)


Public Health

First Advisor's Name

Diana M. Sheehan

First Advisor's Committee Title

Committee chair

Second Advisor's Name

Mary Jo Trepka

Second Advisor's Committee Title

Committee member

Third Advisor's Name

Zoran Bursac

Third Advisor's Committee Title

Committee chair

Fourth Advisor's Name

Dionne Stephens

Fourth Advisor's Committee Title

Committee member

Fifth Advisor's Name

Purnima Madhivanan

Fifth Advisor's Committee Title

Committee member


latent class analysis, low birth weight, pregnancy, preterm birth, risk factors

Date of Defense



This dissertation examined the mediators, moderators, and high-risk latent classes of preterm birth (PTB) and low birth weight (LBW) among pregnant women in rural Mysore District, India. Secondary data analyses of a prospective cohort study conducted between 2011-2014 among 1540 women was performed to complete this dissertation.

In the first study, we examined the association between socioeconomic status (SES) and PTB and LBW. Latent class analysis (LCA) was performed to assess sociodemographic patterns of high-risk pregnant women based on education, income, marital status, primigravida status and number of children. We identified four distinct classes, Class 1 “low SES/early marriage/multigravida/1 child or more”, Class 2 “low SES/later marriage/primigravida/no children”, Class 3 “high SES/later marriage/multigravida/1 child or more”, and Class 4 “high SES,/later marriage/primigravida/no children”. Women in Class 1 (aOR: 1.77, 95% CI: 1.05-2.97 ) and Class 2 (aOR: 2.52, 95% CI: 1.51-4.22) had higher odds of PTB and LBW, respectively.

In the second study, we examined the moderating role of Accredited Social Health Activists (ASHA) home visits and ASHA-accompanied antenatal care visits (ANC) on the relationship between sociodemographic latent classes (identified in the first study) and PTB and LBW. Women in Class 1 and Class 3 who never or rarely had ASHA-accompanied ANC visits had higher odds of PTB (aOR: 2.62 95% CI: 1.12-6.12, aOR: 3.47 95% CI:1.31-9.15, respectively).

Lastly, we examined the mediating role of anemia in the relationship between low SES and PTB and LBW. Employing LCA on relevant SES measures i.e., income, education, occupation and early marriage, we identified two distinct classes: Class 1 “low SES and early marriage” and Class 2 “high SES and later marriage”. Findings suggested a significant direct effect of Class 1 on LBW (adjusted odds ratio [aOR]: 2.11, 95% confidence interval [CI]: 1.43-3.45), but no significant indirect effects (aOR: 0.99, 95% CI: 0.95-1.00.)

In conclusion, belonging to a low SES class emerged as the strongest predictor of PTB and LBW, and tailored interventions for this demographic group are needed to reduce socioeconomic inequities. While our study did not observe anemia as a significant mediator, future studies should explore other mediators such as infections and inflammatory markers. Further, strengthening the ASHA program is vital for quality-care home visits and uptake of ANC visits, which may ultimately reduce PTB and LBW in rural India.






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