It is well known that preterm birth rates are higher in the U.S. than in other developed countries, and preterm birth rates are higher in Alabama than in many other states in the U.S. While our natural inclination is to look for weaknesses in the health care system or health care system access that might explain these rates, the preterm birth rate is actually not that responsive to changes in health care. This presentation explores an alternative explanation: that more child-bearing age women in the U.S. are exposed to some of the major population-level risks for preterm birth, compared to women in other countries. We compare exposures at the pregnancy, individual, community and policy levels and identify the key ways that the U.S. differs from other countries. We then consider which of these factors also differentiate Alabama from other states.