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Comparative Study
. 2020 Nov;146(5):e20200464.
doi: 10.1542/peds.2020-0464. Epub 2020 Oct 19.

Infant Mortality in Rural and Nonrural Counties in the United States

Deborah B Ehrenthal  1   2 , Hsiang-Hui Daphne Kuo  3 , Russell S Kirby  4
Affiliations
Comparative Study

Infant Mortality in Rural and Nonrural Counties in the United States

Deborah B Ehrenthal et al. Pediatrics. 2020 Nov.

Abstract

Background and objectives: Rural counties have the highest infant mortality rates across the United States when compared with rates in more urban counties. We use a social-ecological framework to explain infant mortality disparities across the rural-urban continuum.

Methods: We created a cohort of all births in the United States linked to infant death records for 2014 to 2016. Records were linked to county-level data from the Area Health Resources File and the American Community Survey and classified using the National Center for Health Statistics Urban-Rural Classification Scheme. Using multilevel generalized linear models, we investigated the association of infant mortality with county urban-rural classification, considering county health system resources and measures of socioeconomic advantage, net of individual-level characteristics, and controlling for US region and county centroid.

Results: Infant mortality rates were highest in noncore (odds ratio [OR] = 1.32, 95% confidence interval [CI]: 1.26-1.39) and micropolitan counties (OR = 1.26, 95% CI: 1.20-1.32) when compared with large metropolitan fringe counties, controlling for geospatial measures. Inclusion of county health system characteristics did little to attenuate the greater odds of infant mortality in rural counties. Instead, a composite measure of county-level socioeconomic advantage was highly protective (adjusted OR = 0.84; 95% CI: 0.82-0.86) and eliminated any difference between the micropolitan and noncore counties and the large metropolitan fringe counties.

Conclusions: Higher infant mortality rates in rural counties are best explained by their greater socioeconomic disadvantage than more-limited access to health care or the greater prevalence of mothers' individual health risks.

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Conflict of interest statement

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Figures

FIGURE 1
FIGURE 1
NCHS urban-rural classification scheme for counties. Reprinted with permission from Ingram DD, Franco SJ. 2013 National Center for Health Statistics (NCHS) urban-rural classification scheme for counties. Vital Health Stat 2. 2014;(166):4.
See this image and copyright information in PMC

Comment in

References

    1. Ely DM, Driscoll AK, Matthews TJ. Infant Mortality Rates in Rural and Urban Areas in the United States, 2014. Hyattsville, MD: National Center for Health Statistics; 2017 - PubMed
    1. Womack LS, Rossen LM, Hirai AH. Urban-rural infant mortality disparities by race and ethnicity and cause of death. Am J Prev Med. 2020;58(2):254–260 - PMC - PubMed
    1. James WL. All rural places are not created equal: revisiting the rural mortality penalty in the United States. Am J Public Health. 2014;104(11):2122–2129 - PMC - PubMed
    1. Singh GK, Siahpush M. Widening rural-urban disparities in all-cause mortality and mortality from major causes of death in the USA, 1969-2009. J Urban Health. 2014;91(2):272–292 - PMC - PubMed
    1. Cosby AG, McDoom-Echebiri MM, James W, Khandekar H, Brown W, Hanna HL. Growth and persistence of place-based mortality in the United States: the rural mortality penalty. Am J Public Health. 2019;109(1):155–162 - PMC - PubMed

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