Prenatal metal exposure has been associated with an increased risk of preterm birth (PTB). In North Carolina (NC), metal exposure may occur via unregulated private wells. Low-income and people of color populations disproportionately exposed to well water metal contamination can be identified via Toxic Metal Environmental Justice Indices (TM-EJI). Four unique TM-EJIs have been previously determined for inorganic arsenic (iAs), cadmium (Cd), lead (Pb), and manganese (Mn). The aim of this study was to assess the relationship between the TM-EJIs and PTB prevalence in NC, at a census tract level. Linear regression models were employed to analyze the relationship between the TM-EJI indicator variables and PTB prevalence. Notably, census tracts with positive Mn TM-EJIs had a significant PTB prevalence on average 0.31% higher than census tracts with Mn TM-EJIs equal to zero. This finding highlights the impact of joint exposure to chemical and non-chemical stressors on PTB risk.