Urban-Rural Differences in Pregnancy-Related Deaths, United States, 2011-2016.

Structured Abstract Background The U.S. pregnancy-related mortality ratio has not improved over the past decade and includes striking disparities by race/ethnicity and by state. Understanding differences in pregnancy-related mortality across and within urban and rural areas can guide the development of interventions for preventing future pregnancy-related deaths. Objective We sought to compare pregnancy-related mortality across and within urban and rural counties by race/ethnicity and age. Study Design We conducted a descriptive analysis of 3,747 pregnancy-related deaths during 2011–2016 (the most recent available) with available ZIP code or county data in the Pregnancy Mortality Surveillance System, among Hispanic and non-Hispanic White, Black, American Indian/Alaska Native, and Asian/Pacific Islander women ages 15–44 years. We aggregated data by U.S. county and grouped counties per the National Center for Health Statistics Urban-Rural Classification Scheme for Counties. We used R statistical software, epitools, to calculate the pregnancy-related mortality ratio (number of pregnancy-related deaths per 100,000 live births) for each urban-rural grouping, obtain 95% confidence intervals, and perform exact tests of ratio comparisons using the Poisson distribution. Results Of the total 3,747 pregnancy-related deaths analyzed, 52% occurred in large metro counties and 7% occurred in noncore (rural) counties. Large metro counties had the lowest pregnancy-related mortality ratio (14.8, 95% CI: 14.2–15.5) while noncore counties had the highest (24.1, 95% CI: 21.4–27.1), including for most race/ethnicity and age groups. Pregnancy-related mortality ratio age disparities increased with rurality. Women ages 25–34 years and ages 35–44 years living in noncore counties had pregnancy-related mortality ratios 1.5 and 3 times higher, respectively, than women of the same age groups in large metro counties. Within each urban-rural category, pregnancy-related mortality ratios were higher among non-Hispanic Black women compared to non-Hispanic White women. Non-Hispanic American Indian/Alaska Native pregnancy-related mortality ratios in small metro, micropolitan, and noncore counties were 2–3 times that of non-Hispanic White women in the same areas. Conclusion Although more than half of pregnancy-related deaths occurred in large metro counties, the pregnancy-related mortality ratio rose with increasing rurality. Disparities existed among urban-rural categories, including by age group and by race/ethnicity. Geographic location is an important context for initiatives to prevent future deaths and eliminate disparities. Further research is needed to better understand reasons for the observed urban-rural differences and to guide a multifactorial response to reduce pregnancy-related deaths.