Preterm Birth in the West Bank, Palestine: Insights From a Hospital‐Based Cohort Study

ABSTRACT

Aim

Preterm birth (PTB), delivery before 37 completed weeks of gestation, remains a major cause of neonatal morbidity and mortality. Evidence from conflict‐affected, resource‐limited settings such as the West Bank, Palestine, is limited. This study aimed to estimate PTB incidence and identify maternal, neonatal and socioeconomic risk factors using hospital‐based data from government facilities.

Methods

A retrospective cohort study utilised the Avicenna Health Information System across three major governmental hospitals in the West Bank. All live births at ≥ 24 weeks' gestation between January 2023 and May 2024 were included. Descriptive statistics, chi‐square tests and multivariable logistic regression were applied to assess PTB‐associated factors.

Results

Among 18,760 live births, 1427 (7.6%) were preterm, mostly moderate to late preterm (7.0%). Higher PTB risk was observed among mothers aged < 20 years (aOR 1.53) or ≥ 35 years (aOR 1.32), male infants (aOR 1.16) and multiple pregnancies (twins aOR 4.98; triplets aOR 17.28). The Ramallah district had the highest PTB rate (aOR 2.35), likely reflecting referral to tertiary care.

Conclusion

PTB incidence was lower than previous national estimates but may underestimate community rates. Findings highlight key determinants and emphasise the need for improved data systems and population‐based perinatal surveillance in Palestine.

Summary.

• One of the first multicentre, hospital‐based studies to assess PTB in the West Bank, Palestine.

• PTB incidence was 7.6%, with a higher risk among younger and older mothers, male infants and multiple pregnancies.

• Although not population‐representative, the study highlights data gaps and supports the establishment of a national perinatal information system to guide equitable maternal and newborn care.

Abbreviations

ANC

antenatal care

AOR

adjusted odds ratio

CI

confidence interval

FTB

full‐term Birth

HIS

Health Information System

NICU

Neonatal Intensive Care Unit

PTB

preterm birth

1. Introduction

Preterm birth (PTB), defined as delivery before 37 completed weeks of gestation, represents a major global public health challenge and remains the leading cause of mortality among children under 5 years of age [1]. Each year, PTB is responsible for approximately 18% of all deaths in this age group and up to 35% of neonatal mortality worldwide. Beyond mortality, PTB contributes substantially to long‐term morbidity, including cerebral palsy, chronic respiratory conditions, sensory deficits and neurodevelopmental impairments. Its multifactorial aetiology arises from a complex interplay of biological, behavioural, environmental and health system‐related determinants, with the burden disproportionately concentrated in low‐ and middle‐income countries [1, 2].

Historically, Palestine encompassed approximately 26 323 km²; however, its contemporary territory is estimated at 6170 km², comprising 5805 km² in the West Bank and 365 km² in the Gaza Strip. The West Bank is further divided into three geographic regions: North (Jenin, Nablus, Tulkarm, Qalqiliya, Tubas and Salfit), Centre (Ramallah and Jericho) and South (Bethlehem and Hebron). Under the Oslo II Accord, the territory is also classified into Areas A, B and C, reflecting varying degrees of Palestinian and Israeli administrative and security control. These geopolitical divisions generate pronounced disparities in health service accessibility and contribute to socioeconomic inequities across districts [3, 4]. The protracted Israeli–Palestinian conflict has resulted in severe human, infrastructural and economic losses, while political instability, movement restrictions and military checkpoints have further hindered access to timely maternal and neonatal care, factors that disproportionately affect high‐risk and underserved populations [5].

In 2023, the West Bank documented approximately 82 510 live births, with hospital‐based deliveries nearly universal (99.9%). Ministry of Health (MoH) facilities accounted for 35 155 of these births. The crude birth rate was 28.1 per 1000 population, while low birth weight (< 2500 g) occurred in 5.2% of newborns [6]. Maternal and child health indicators continue to fall short of global benchmarks. Between 2015 and 2019, the under‐five mortality rate was 14 per 1000 live births, and PTB prevalence was estimated at 13%, exceeding the global average of approximately 10% [7]. Neonatal mortality in the region also surpasses the targets of Sustainable Development Goal (SDG) 3.2, which calls for reducing neonatal deaths to 12 per 1000 live births by 2030 [8]. These gaps underscore the persistent inequities within a fragile, resource‐constrained and politically complex healthcare system.

Despite the public health urgency, epidemiological evidence on PTB incidence and determinants in Palestine remains limited and fragmented. The absence of a population‐based perinatal surveillance system, coupled with inconsistent reporting across governmental, private and NGO sectors, hinders comprehensive monitoring of maternal and neonatal outcomes. Political fragmentation, inconsistent electronic medical record use and logistical barriers further restrict data integration and continuity of care. As a result, hospital‐based data currently offer the most reliable source for examining PTB patterns in the West Bank. Although hospital deliveries are nearly universal, digital clinical documentation using the Avicenna Health Information System (HIS) is primarily implemented in governmental hospitals.

Using HIS‐derived data, this retrospective hospital‐based cohort study estimates the incidence of PTB and examines its maternal, neonatal and socioeconomic determinants within governmental healthcare settings in the West Bank. While the findings do not represent all births in the territory, they contribute essential, context‐specific evidence to inform maternal and newborn health policies, guide resource allocation and highlight the urgent need for establishing a robust, population‐based perinatal surveillance system to ensure comprehensive and reliable monitoring across Palestine.

2. Method

2.1. Study Design

This 17‐month retrospective hospital‐based cohort study utilised registry data from the HIS in the West Bank, Palestine. The HIS was established to capture routinely collected hospital data on parturient mothers and their newborns.

2.2. Study Setting

This study was conducted in three purposefully chosen government hospitals in the West Bank to assess the region's healthcare heterogeneity. The hospital selection was based on the availability of neonatal intensive care units (NICUs), demographic catchment and their ability to represent various healthcare concerns, including those induced by ongoing conflict. The first hospital, located in Jenin, represents the northern West Bank; the second, in Ramallah, represents the middle area and the third, in Hebron, represents the southern West Bank.

2.3. Data Collection and Quality

With formal approval from the MoH, birth records from the participating hospitals covering the period January 2023 to May 2024 were retrieved from the Hospital Information System (HIS) by trained personnel under the supervision of the principal investigator. A structured data collection checklist was specifically developed to ensure standardised and accurate extraction of all relevant variables. The checklist was informed by a review of the literature and expert consultation, and it underwent pilot testing before finalisation, incorporating feedback from a panel that included MoH representatives.

Data were extracted directly from the HIS using this standardised tool, and random cross‐checks were performed to verify completeness, accuracy and internal consistency. All datasets were stored securely in a password‐protected Excel file, ensuring confidentiality and maintaining data integrity throughout the study.

2.4. Population

This retrospective cohort study included all mothers who delivered live‐born infants at the three selected hospitals in the West Bank between January 2023 and May 2024, during which a total of 19 425 live births were recorded. Mothers were eligible for inclusion if their medical records contained complete data on the study variables. Records with missing data or deliveries occurring outside the specified study period were excluded from the analysis.

2.5. Data Analysis

Analysis of data was performed using R statistical software, version 4.3.1. Maternal, obstetric and foetal characteristics were expressed in frequencies and percentages. The overall incidence of preterm delivery was calculated, and chi‐square tests were used to examine the association of preterm delivery with categorical features such as education, age and pregnancy complications. Univariate logistic regression was used to evaluate the potential risk variables first, and multivariate logistic regression was used to adjust for confounders and quantify independent predictors. The results are presented as adjusted odds ratios (AOR) with 95% confidence intervals (CI), and the significance level is p < 0.05.

2.6. Ethical Considerations

Ethical approval for this study was obtained from the Research Ethics Committee of Al‐Quds University (Ref. No. 505/REC/2025) and the Palestinian MoH. All procedures were conducted in accordance with relevant ethical guidelines and regulations. Confidentiality of patient information was strictly maintained throughout the study by anonymising data and securely storing records in password‐protected files accessible only to authorised personnel.

3. Results

3.1. Incidence of Preterm Birth

All newborns delivered at ≥ 24 weeks of gestation between January 2023 and May 2024 at the selected West Bank hospitals were included. Out of the 19 425 recorded live births, 665 were excluded due to missing data on gestational age, infant sex or maternal age, resulting in a final sample of 18 760 live births for analysis. Among these, 1427 (7.6%) were PTBs, categorised as follows: 23 (0.12%) extreme preterm (< 28 weeks), 84 (0.45%) very preterm (28– < 32 weeks) and 1320 (7.0%) moderate to late preterm (32– < 37 weeks). Due to the small number of extremely preterm cases, the extremely and very preterm categories were combined in some analyses as “extreme‐to‐very preterm” (< 32 weeks). The remaining 17 333 (92.4%) were term births, consisting of 2825 (16.3%) early‐term (37– < 39 weeks) and 14 508 (83.7%) full‐term (39–42 weeks) births (Figure 1).

FIGURE 1.

Flowchart of the study population: distribution of term and preterm infants. Note: preterm birth (PTB) is defined as birth before 37 completed weeks of gestation and is categorised as extremely preterm (< 28 weeks), very preterm (28– < 32 weeks) and moderate to late preterm (32– < 37 weeks) [1]. Full‐term birth (FTB) is 39 + 0 to 40 + 6 weeks, and early term birth (ETB) is 37 + 0 to 38 + 6 weeks [9].

3.2. Participants' Characteristics

During the study period, 19 425 women delivered in the selected hospitals. Most PTBs occurred in hospitals in the central hospital (Ramallah) (76.2%), whereas full‐term births were more evenly distributed across districts. Regarding maternal age, 14.1% of mothers with PTB were ≥ 35 years compared to 11.7% with full‐term births (FTB). The majority of mothers were aged 20–34 years (78.6% PTB vs. 82.6% FTB), while younger mothers (< 20 years) accounted for 7.3% of PTB and 5.6% of FTB.

In terms of maternal occupation, most were unemployed (91.5% PTB vs. 94.4% FTB), while smaller proportions were employed in government (3.6% PTB vs. 2.6% FTB) or nongovernmental jobs (4.9% PTB vs. 3.0% FTB). Preterm infants were more likely to have very low birth weight (< 1500 g; 30.6% vs. 5.8%) or low birth weight (1500–2499 g; 68.9% vs. 91.7%) compared to full‐term infants. Multiple births were also more frequent among PTB (22.9%) than FTB (4.1%). Antenatal care attendance was similar across groups; however, a smaller proportion of mothers with PTB had < 8 visits (24.5% vs. 31.9%) (Table 1).

TABLE 1.

Characteristics of the study population according to gestational age groups: Demographic, foetal and obstetric variables comparing preterm and full‐term births.

Variable	Category	Preterm births (n = 1427) n (%)	Full‐term births (n = 17 814) n (%)	p
Maternal age	< 20y	104 (7.3)	1006 (5.6)	0.001
	20–34 y	1122 (78.6)	14 718 (82.6)
	> 35y	201 (14.1)	2090 (11.7)
Mother occupation	Government	52 (3.6)	469 (2.6)	0.001
	Nongovernment	70 (4.9)	531 (3)
	Unemployed	1305 (91.5)	16 814 (94.4)
Baby weight	Very low (< 1500 g)	436 (30.6)	1025 (5.8)	0.001
	Low (1500–2499 g)	983 (68.9)	16 333 (91.8)
	Normal (2500–3999 g)	8 (0.6)	455 (2.6)
Baby sex	Female	658 (46.1)	8708 (48.9)	0.1254
	Male	769 (53.9)	9105 (51.1)
Birth type	Single	1100 (77.1)	17 100 (96)	0.001
	Twins	313 (21.9)	704 (4)
	Multiple ≥ 3	14 (1)	10 (0.1)
Hospital region	Jenin district ‘North’	71 (5)	7073 (39.7)	0.001
	Ramallah district ‘Central’	1087 (76.2)	5321 (29.9)
	Hebron district ‘South’	269 (18.9)	5420 (30.4)
Antenatal Follow‐up	Yes	1427 (100)	17 788 (99.9)	0.301
	No	0 (0)	25 (0.1)
Number of ANC visits	> 8	1077 (75.5)	12 123 (68.1)	0.001
	< 8	350 (24.5)	5691 (31.9)

Abbreviations: ANC, antenatal care; FTB, full‐term birth; n, number; (%), percentage; PTB, preterm birth.

3.3. Risk Factors of Preterm Delivery

Multivariable logistic regression identified several additional statistically significant risk factors for preterm delivery (Table 2). Mothers younger than 20 years had a 53% increased risk of preterm delivery compared with mothers aged 20–34 years (aOR 1.53), while maternal age ≥ 35 years was associated with a 32% increase in risk (aOR 1.32). Male infants demonstrated a slightly higher risk than female infants (aOR 1.16). Multiple pregnancy was strongly associated with PTB, with twins exhibiting nearly fivefold higher risk (aOR 4.98) and triplets more than seventeenfold higher risk (aOR 17.28) compared with singletons. Fewer than seven prenatal visits were not significantly associated with PTB (aOR 1.12, p = 0.12).

TABLE 2.

Multivariable logistic regression analyses of the risk factors associated with preterm babies.

Category	Subgroup	Adjusted odds ratio aOR (95% CI)	p
Maternal age	< 20y	1.53 (1.21–1.93)	0.001
	20–34 y	1.00 (ref)	—
	> 35y	1.32 (1.11–1.57)	0.01
Mother occupation	Government	1.00 (ref)	—
	Nongovernment	1.06 (0.77–1.47)	0.91
	Unemployed	1.31 (0.8–2.12)	0.45
Baby sex	Female	1.00 (ref)	—
	Male	1.16 (1.03–1.31)	0.05
Birth type	Single	1.00 (ref)	—
	Twins	4.98 (4.16–5.97)	0.001
	Multiple ≥ 3	17.28 (6.54–45.65)	0.001
Pregnancy care visits	> 8	1.00 (ref)	—
	< 8	1.12 (0.87–1.44)	0.12
Hospital region	Jenin district ‘North’	1.00 (ref)	—
	Ramallah district ‘Central’	23.5 (14.64–37.74)	0.001
	Hebron district ‘South’	5.62 (2.76–11.44)	< 0.001

Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; Ref, referent.

Regional variation was apparent, with the central hospital (Ramallah) showing markedly higher odds of preterm delivery (aOR 23.5) and the southern hospital (Hebron) also demonstrating elevated risk (aOR 5.62), compared with the northern hospital (Jenin). Birth weight was not included as a predictor in the multivariable model because it is an outcome of PTM rather than an antecedent risk factor.

4. Discussion

This study estimated the incidence of PTB and identified associated risk factors among Palestinian mothers in the West Bank using hospital‐based data from three major governmental facilities. As these hospitals capture only a portion of regional deliveries, the findings reflect institutional‐level patterns rather than population‐wide estimates. Nevertheless, they provide valuable evidence from a context where robust national data remain limited.

The observed PTB incidence of 7.6% aligns with rates reported in several high‐income countries, such as Finland, Sweden and New Zealand [10], but remains below the estimated 13.2% for the occupied Palestinian territory (oPt) in 2010 and 2020 [11]. While informative, these results should not be interpreted as representative of the entire West Bank. Data were retrospectively collected from a subset of governmental hospitals and may not include births in private, rural or NGO facilities, which together account for a substantial proportion of deliveries.

The unexpectedly low PTB rate contrasts with the well‐documented socioeconomic and health system challenges in the West Bank, including restricted movement, fragmented health services and prolonged political instability. Geographic heterogeneity likely contributes to this difference, as national PTB estimates for the oPt encompass both the West Bank and Gaza. The Gaza Strip faces severe socioeconomic hardship, barriers to healthcare access and an ongoing humanitarian crisis, all of which have been associated with increased PTB risk and rising PMBs in recent years [12, 13].

Data quality within the Avicenna HIS may also influence these findings. Although HIS has been implemented across most governmental hospitals, evaluations highlight persistent technological, organisational and human‐resource barriers that compromise data completeness and accuracy [14, 15]. Inconsistent documentation, fragmented data entry practices and limited staff training may have resulted in underreporting or misclassification, potentially underestimating the true PTB rate. Consequently, these findings should be interpreted as indicative rather than definitive estimates of PTB in the West Bank.

These observations emphasise the urgent need to assess the reliability, completeness and interoperability of routine HIS data in Palestine and to establish a comprehensive, population‐based perinatal registry. Such a system would enhance the precision of national maternal and newborn health statistics and support equitable health policy planning. Despite the limitations of institutional data, hospital‐based analyses remain essential for identifying information gaps and advocating for improved data governance. Strengthening HIS infrastructure and ensuring standardised, accurate and timely data entry are critical for evidence‐informed decision‐making, particularly in conflict‐affected settings where routine reporting is often fragmented.

Consistent with global evidence, the risk of PTB was significantly higher among both younger mothers (< 20 years) and older mothers (≥ 35 years), aligning with established biological and obstetric vulnerabilities at the extremes of reproductive age [16, 17]. The majority of mothers in this cohort were aged 20–34 years, representing the lowest‐risk age group, and all reported receiving antenatal care (ANC). Notably, 75.5% of PTB cases occurred among women who had attended at least eight ANC visits, meeting the World Health Organisation's recommended minimum for positive pregnancy outcomes [18]. Although high ANC coverage is encouraging, this finding underscores that the quality, timeliness and continuity of ANC, rather than visit frequency alone, remain critical determinants of maternal and neonatal health in the study setting.

Unemployment was prevalent among both PTB and full‐term groups (91.5% and 94.4% respectively), reflecting broader structural economic challenges and the reliance on public hospitals for affordable care. Employment may facilitate healthcare access, but certain working conditions, such as long hours, prolonged standing and shift work, have been associated with increased PTB risk [19]. Conversely, unemployment and social vulnerability can also heighten PTB risk through stress and limited resources [20]. This duality underscores the complex interplay between socioeconomic status, employment and reproductive health outcomes.

Marked regional disparities were evident among the study hospitals. The central hospital accounted for the highest proportion of PTBs (76.2%) and demonstrated an adjusted odds ratio of 2.35 compared with the southern hospital. This pattern likely reflects referral bias, as the central hospital functions as a major tertiary referral centre and offers more advanced neonatal intensive care services. Consequently, these differences appear to be driven predominantly by the organisation of the healthcare system and referral pathways rather than by true population‐level variations in PTB risk.

In line with previous evidence, very low birth weight (< 1500 g) was a strong predictor of PTB, while normal birth weight was protective [21, 22, 23, 24]. Male infants exhibited slightly higher odds of PTB, consistent with global findings [25], likely due to greater intrauterine vulnerability to stress. Multiple pregnancies carried a markedly higher risk, with twins showing nearly fivefold and higher‐order multiples 17‐fold greater odds of PTB compared to singletons [26]. These associations highlight the need for targeted monitoring and specialised obstetric care for high‐risk pregnancies.

While the identified determinants align with global patterns, their relative distribution in this context provides nuanced insight into the interplay of biological, social and system‐level factors within a politically and economically constrained environment. Given the limited representativeness of hospital‐based data, these findings should be interpreted as an important step towards establishing more comprehensive national surveillance. Strengthening data quality within the HIS and expanding population‐based perinatal surveillance across all hospitals and birthing facilities are essential to producing representative and reliable evidence. Such efforts are crucial for informing equitable maternal and newborn health policies and for advancing national progress towards achieving Sustainable Development Goal 3.2.

5. Strengths and Limitations

This study represents one of the first multicentre assessments of preterm and early term births in the West Bank, utilising routinely collected data from 18 760 live births across three governmental hospitals. Its large sample size and standardised data extraction processes support meaningful internal comparisons and enable identification of maternal and obstetric risk patterns.

However, several limitations warrant consideration. First, the findings are not representative of all births in the West Bank. The analysis was restricted to selected governmental hospitals, excluding private, NGO and rural facilities, many of which continue to rely on paper‐based documentation. Second, data incompleteness presented challenges; 665 births were excluded due to missing information, introducing the possibility of selection bias. The hospital‐based design also limits the generalisability of the findings, particularly to Gaza, where healthcare access, socioeconomic conditions and obstetric practices differ significantly.

Additionally, the unexpectedly low PTB rate observed in this study may reflect underreporting or misclassification within the Avicenna HIS. Previous evaluations have identified inconsistencies in data entry, limited staff training and variable adherence to documentation standards, all of which may have contributed to an underestimation of the true PTB incidence. Moreover, several potentially important confounders, such as maternal nutrition, psychosocial stress, infection or fertility treatments, were not available in the dataset, limiting causal inference.

Despite these limitations, this study provides valuable institutional‐level insights into PTB determinants and highlights critical gaps in data quality and coverage. These findings underscore the urgent need to strengthen HIS accuracy, completeness and interoperability and to develop a comprehensive, population‐based perinatal registry capable of supporting reliable and representative monitoring of maternal and newborn health outcomes in Palestine.

6. Conclusion

This multicentre, hospital‐based cohort study provides foundational evidence on the incidence and determinants of PTB in the West Bank, Palestine, while also emphasising persistent challenges related to data completeness and representativeness within national health information systems. The observed PTB incidence of 7.6%, although lower than previous national estimates, should be interpreted cautiously in light of limited facility coverage and the potential for underreporting within the Avicenna HIS. Consistent with global literature, higher PTB risk was observed among younger mothers (< 20 years), older mothers (≥ 35 years), multiple pregnancies and male infants. The concentration of PTB cases in Ramallah likely reflects referral patterns and the availability of tertiary‐level neonatal care rather than true geographic variation. Despite high antenatal care utilisation, the findings indicate potential gaps in care quality and timeliness that merit further investigation.

Although not representative of all births in the West Bank, this study provides the most comprehensive hospital‐based dataset currently available and offers important insight into the interplay of maternal, clinical and system‐level factors influencing PTB in a politically and economically constrained setting. Strengthening the national HIS, improving data accuracy and establishing a comprehensive population‐based perinatal registry are essential to generating reliable, representative evidence that can inform maternal and newborn health policy. Transparent and systematic use of routine hospital data, combined with continuous data quality assurance, can lay the foundation for robust surveillance systems and accelerate progress towards achieving Sustainable Development Goal 3.2 on reducing neonatal mortality in Palestine and other conflict‐affected contexts.

Author Contributions

Amani Salem Ahmad Salim: conceptualisation, data curation, formal analysis, investigation, methodology, writing – original and draft preparation. Prof. Dr Ewa‐Lena Bratt: supervision, data curation, investigation, methodology, writing – review and editing. Dr Kawther Elissa: supervision, conceptualisation, methodology, writing, review and editing.

Funding

The authors have nothing to report.

Disclosure

AI: The authors used AI‐assisted tools exclusively to enhance language, grammar and readability. No generative AI was employed in study design, data collection, analysis, interpretation or the writing of scientific content.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.