Health and socioeconomic characteristics underlying educational attainment of children born preterm in England: a population cohort study using linked data

BackgroundPreterm birth (PTB) is a leading cause of atypical brain development and cognitive impairment, however, there are sparse data on its impact on statutory educational assessments. We aimed to describe school readiness at 5 years and educational attainment at 6-7 years of children born preterm in England and identify the early life factors that associate with attainment. MethodsWe created a novel record linkage between the National Neonatal Research Database and the National Pupil Database for all babies born <32 weeks gestation in England (2008-2012) who survived to neonatal discharge. We used logistic regression to investigate associations between clinical and demographic variables and performance in six statutory school-age assessments. FindingsData from 15,857 children were analysed (53.3% boys). Fifty-seven percent did not meet the school readiness level at age 5, 51% did not meet expected attainment at ages six to seven in writing, maths (48%), reading (42%), and science (36%). Children born at 23-24 weeks had two to three times higher odds of not meeting expected levels compared to those born at 31 weeks (age 5: adjusted odds ratio 2.86, 95% CI 2.19-3.73). Children born in the most deprived areas at birth had 1 7 to 2-fold the risk of under-attainment compared to those in the least deprived. In adjusted models, male sex and season of birth conferred increased risk, alongside several potentially mutable risks: smoking during pregnancy, exposure to ante-or postnatal corticosteroids, severe acquired neonatal brain injuries, co-morbidities of PTB, nutrition during neonatal care, and childhood deprivation. InterpretationPTB poses a substantial risk for educational under-attainment at ages 5 through 7 years, particularly when combined with socioeconomic deprivation. Addressing neighbourhood-and family-level social inequalities should be given similar priority as reducing medical complications of PTB for improving the educational attainment of children born preterm. FundingUKRI Medical Research Council RESEARCH IN CONTEXTO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed from October 1st, 2015, to October 1st, 2025, with no language restrictions for publications using the terms (("preterm" OR "premature" OR "gestational age") AND "socioeconomic" AND ("school" OR "education")) in the title/abstract. Our search identified 20 relevant peer-reviewed studies, including one narrative systematic review that examined how socioeconomic inequalities and preterm birth interact to modify health and education outcomes. Three studies were conducted in the UK and used linked data to investigate educational outcomes for preterm-born children. The remainder were conducted in Scandinavian countries, Canada, Australia, and the Netherlands. Collectively, these studies have consistently shown that children born preterm have lower educational attainment compared with those born at term: a well-established dose-response relationship exists between gestational age and educational outcomes, with lower gestational age associated with progressively poorer attainment across all stages of education. However, most existing linkage studies did not capture the clinical heterogeneity of the preterm-born population underlying this gradient, as these data are rarely available in population-level datasets linked to education records. Whilst some studies included measures of socioeconomic status as a covariate, their independent effects have seldom been investigated, particularly relative to neonatal risk factors. Added value of this studyThe present study addresses these gaps through a novel linkage of population-level neonatal clinical data with national statutory educational assessments. We describe the high prevalence of low attainment among very preterm children (<32 weeks gestation) at ages 5 through 7 years in England. The linkage enables a granular characterisation of how maternal and neonatal conditions, exposures and treatments, and neighbourhood-and family-level measures of social disadvantage explain educational performance of children born <32 weeks gestation. The findings show a dose effect of low GA on low attainment and that the adverse effects of socioeconomic deprivation at birth persist through early school age. The effect of family-level deprivation at the start of school age is comparable in magnitude to that of severe neonatal brain injury, however, impacts a greater proportion of the population. As such, this study provides a more holistic understanding of the pathways underlying educational risk in this population. Implications of all the available evidenceImproving the educational attainment of very preterm children is likely to require a reduction in social inequalities in pregnancy and early childhood, alongside care practices and research to minimise comorbidities of preterm birth. Furthermore, the identification of modifiable exposures, including maternal non-smoking, antenatal or postnatal corticosteroid exposure, breastfeeding, and deferred school entry or targeted additional support for very preterm children born in the summer months, offers practical targets for parents, clinicians, teachers and school leaders and educators, that could facilitate long-term educational attainment for children born preterm.