Background <p>Many pre-pregnancy and gestational exposures, such as maternal physical health, behavioral factors, psychosocial adversities, and environmental conditions during pregnancy, influence birth outcomes. These risk factors can co-occur, particularly among populations that experience health disparities, yet much of past researchers tend to examine them in isolation, which may lead inadvertently to some underestimation or mis-specification of risk. Therefore, this study examined the joint contribution of several maternal physical health, behaviors, psychosocial adversities, and environmental conditions during pregnancy on birth outcomes, and whether disparities were evident according to infant sex, maternal race/ethnicity, and education attainment.</p> Methods <p>Participants were from the Albany Infant and Mother Study, a prospective observational cohort of socioeconomic and racial/ethnic diverse pregnant women and their infants (<i>n</i> = 291). Latent Class Analysis was employed to identify discrete groups with different levels and combinations of the following prenatal exposures: maternal health (pre-pregnancy body mass index, pregnancy conditions), behaviors (smoking, recreational drug use, western diet), psychosocial (depression, adverse childhood experiences, social support), and physical environment (lead exposure, indoor environmental contaminants). Linear regression analysis tested associations between exposure classes and birth outcomes.</p> Results <p>Three latent classes were identified: Class 1 (47.7%; low-risk in all domains), Class 2 (42.9%; high-risk across all domains), and Class 3 (9.4%; high-risk in behavioral and environmental domains, but lower health and psychosocial risks). Compared to the low-risk referent Class 1, Class 2 was associated with lower birth weight, length, head circumference, more restricted fetal growth, and earlier gestational age at delivery (all <i>p</i> &lt; 0.05). Class 3 infants also had marginally lower birth weight and increased intrauterine growth restriction (all <i>p</i> &lt; 0.10). Associations were strongest among male infants, and participants from racial/ethnic and lower education backgrounds.</p> Conclusions <p>This comprehensive examination of the combined effects of multiple exposures—encompassing physical health, behavioral, psychosocial and environmental domains— indicated that different patterns of multiple perinatal risks work in combination to influence birth outcomes and disparities at the earliest time in the life course. Research and practice focused on inequalities in maternal and perinatal health should consider the coordinated impacts of multiple risks simultaneously.</p>