1. Beal, Judy A. DNSc, RN, FNAP, FAAN

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It has been well documented that people living in rural communities are at higher risk for poorer health outcomes, including infant mortality, than those living in urban centers. Poor health outcomes and disproportionally higher infant mortality rates regardless of residence zip code have been shown to be associated with risk factors of obesity, substance abuse, smoking, and poverty, all of which are more prevalent in rural or nonmetropolitan communities. Compounding these health issues, people in rural communities are more likely to have limited access to health care providers and other resources.


In 2020, two studies were published that highlight these stark disparities in health outcomes. Although prior research has documented a significantly higher rate of infant mortality in rural areas, most studies have focused on individual maternal contributing factors and few have explored this trend from the perspectives of race or ethnicity or from a broader lens of social determinant of health. In an article in The American Journal of Preventive Medicine, Womack et al. (2020) focused on disparities in rural infant mortality and death by race and ethnicity. This was a well-designed study using data from the 2019 resident infant death files from the National Vital Statistics database. Infant mortality rates were compared using the following categories: county classification (metropolitan, medium/small metropolitan, and nonmetropolitan), maternal race and ethnicity (white, non-Hispanic; black, non-Hispanic; Hispanic; Asian or Pacific Islander; and American Indian or Alaskan Native), and cause of death (congenital anomalies, preterm condition, sudden infant death, infection, injury, and all others). Infant mortality rates ranged from 5.43 deaths per 1,000 live births in large metropolitan counties to 6.67 in counties in nonmetropolitan or rural areas. Infant mortality rates in rural areas were lowest for Hispanic infants and highest for American Indian/Alaskan Natives and whites, non-Hispanic. Regardless of race and ethnicity, mortality was most often associated with sudden infant deaths and congenital anomalies in both nonmetropolitan and medium-to-small metropolitan communities. This trend was consistent across location with the exception of the finding that preterm-related and sudden unexpected death accounted for the majority of deaths for black, non-Hispanic infants.


In another study in Pediatrics, researchers focused their examination on the significant infant mortality disparities across the rural-urban continuum on a broader measure of community socioeconomic or structural injustices (Ehrenthal et al., 2020). Using a social-ecological approach as per Krieger (2000) afforded the investigators to go beyond individual health behaviors to guide their analysis. Using data from the Area Health Resources File, the American Community Survey, and the National Center for Health Statistics Urban-Rural Classification Scheme, Ehrenthal et al. (2020) created multilevel regression analysis models for a final sample of 11,881,814 incidents representing 99.7% of all U.S. resident births from 2014 to 2016. Mortality rates were modeled against the independent variables of rurality and urbanicity, county socioeconomic advantage rates, population statistics (race, family size, and fertility rates), and individual-level factors associated with infant mortality (smoking, gestational diabetes, chronic hypertension, gestational hypertension, preeclampsia, prepregnancy BMI, and birth by a physician). The researchers concluded that higher infant mortality rates in rural communities are significantly associated with socioeconomic disadvantage rather than individual maternal contributing factors.


Findings from both of these cutting-edge studies point to the urgent need for health care providers to focus our energy on advocating for policies that will close this urban-rural gap of disparity. One such approach for pediatric nurses is to advocate for evidence-based programs that provide nurse home visits, food access, and social supports targeted in rural zip codes across the lifespan continuum. Support of policies and practices that support and encourage health care practices, including pediatrics, and hospitals in rural areas is critical. Expanding Medicaid in all states can be an effective strategy to ensure financial survival of rural health care and thus rural residents.




Ehrenthal D. B., Kuo H. D., Kirby R. S. (2020). Infant mortality in rural and nonrural counties in the United States. Pediatrics, 146(5), e20200464.[Context Link]


Krieger N. (2000). Epidemiology and social sciences: Towards a critical reengagement in the 21st century. Epidemiologic Reviews, 22(1), 155-163. [Context Link]


Womack L. S., Rossen L. M., Hirai A. H. (2020). Urban-rural infant mortality disparities by race and ethnicity and cause of death. American Journal of Preventive Medicine, 58(2), 254-260.[Context Link]