Abstract Objectives: to identify and evaluate which psychosocial criteria are associated with preterm birth in a midwifery model of risk in pregnancy. Design: a quantitative study with a prospective correlational research design. Setting: women attending three prenatal clinics in East Tennessee. Participants: 120 pregnant women between 16 and 28 weeks gestation. The majority of the clinics’ clients were from rural Appalachia. Measurements and findings: multiple logistic regression statistical analysis revealed that women with symptoms of depression, lower levels of self-esteem, or a negative perception of pregnancy had significantly higher odds of delivering a preterm baby. Key conclusions and implications for practice: these findings suggest the importance of screening for psychosocial risk factors in pregnancy. Interventions to address these psychosocial risks could improve maternal psychosocial health, maintain continuity of midwifery care, and reduce the incidence of preterm birth.